MONTANA UNIVERSITY SYSTEM
Request for Refund
of Excess Fees Paid Because of Simultaneous Attendance
at Two Campuses of the Montana University System
M.I.
STATE ZIP
Date
1
2
3
COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5
Actual Amount
Paid
Total) at
Campus Rate
Actual Amount
Paid
Total) at
Campus Rate
(Col. 1 + 3)
4
5
6
7
8
9
10
11
12
13
14
15
DATE
Institution Names
Total
Credits
NAME AND TITLE
CAMPUS
Credits Carried
Amount that should have been paid (Line 9 [column 2 or 4] X
Line 10)
Enter amount from Line 11
Amount of refund (Line 9 - Line 12)
Add: Refund* for activity and health service fees at one unit if
paid at both
Signature
Health Service Fees
F O R O F F I C E U S E O N L Y
Names of Campuses Attended
Social
Security
Number
Dates of Attendance
Receipt Numbers
Building Fees
Nonresident Building Fees
Student Activity Fees
Registration Fees
Incidental Fees
Computation of Refund
Mailing Address
LAST NAME FIRST NAME
Name
CITYP.O. BOX OR STREET ADDRESS
SIGNATURE
Prepared By
Institution A Institution B
TOTAL refund (Line 13 + Line 14)
* This refund entails relinquishment of student activity and health service identification cards at the unit where the student resided for the minor portion of the
semester.
Nonresident Incidental Fees
TOTALS
Ratio of credit hours taken at each unit over total credit hours
