Refund Request-Excelsior
Return form to: University at Buffalo
Student Accounts
1 Campus Mail Center
Buffalo, NY 14260
Phone: 716-645-1800 Fax: 716-645-7771
Scholarship Information
Student currently has anticipated aid for (please check all that apply): Refund requested for:
_____Excelsior Scholarship Estimate _____ Excelsior Tuition Credit Estimate _____Spring _____Fall
Student eligibility for the Excelsior scholarship may change over time and the adjustment of tuition and other awards may result in
the student owing a balance to the university as a result of this refund. Any amount owed after adjustment of the financial aid
awards will be billed to the student. Students receiving the Excelsior scholarship are urged to consult with a Financial Aid or
Academic Advisor before submitting a refund request. Please be advised that your current term’s TAP award must be disbursed
before your Excelsior refund request can be processed. TAP disbursement typically occurs after the fifth week of class.
Student Information
Full Name: _______________________________________________________________________________
Last First M.I.
Address: _______________________________________________________________________________
Street Address
City State Zip Code
Home Phone: _____________________________________ UB Person Number: _________________________
Email Address: ___________________ @buffalo.edu
Certification and Signature
I understand that by requesting this manual refund, I acknowledge that it is based upon the anticipated Excelsior Scholarship and
Excelsior Tuition Credit that I am currently eligible to receive. I also acknowledge that my meeting the criteria to receive this
scholarship is subject to change, potentially as late as the following summer. I understand that at a later time (in this or a future
semester), if my Excelsior award amount is reduced or goes to zero, I will be responsible for repaying the amount that is being
refunded today.
Please note, refunds will be issued via direct deposit where applicable. If direct deposit is not available, a paper check will be issued.
Checks will be sent to the residence hall or local address listed in HUB while classes are in session. During semester breaks, refund
checks will be mailed to the permanent address listed in HUB. For timely receipt of the refund check, be sure to verify all address
information is current.
By signing this form, I accept that if I no longer meet the criteria to receive the Excelsior Scholarship and Excelsior Tuition Credit or if
the award amount is reduced, my student account will be adjusted and I will owe this refund back to the university.
Signed: _________________________________________________________Date:__________________________
student signature
Office Use Only-Student Accounts
Received: ______________ Processed by:___________ Amount $_______________ Date: _____________