Fillable Refund.request.form Please Print: SID# Or M.I. Number & Street (San Jose City College)

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Refund.request.form Please Print: SID# Or M.I. Number & Street (San Jose City College)

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Please Print: SID# or
Name: SS#
M.I.
Please send my refund to the following address:
Address:
Number & Street
( )
State
Is this an address change? .
I am requesting a refund for SJCC or EVC for the /
Semester / Year (One form per session)
The approximate amount of my refund is $
Reason(s) For Refund: Please mark the correct reason(s)
I have officially dropped the following classes: (One-time processing fee charged per term)
Start Date
End Date Drop Date Units
Reg.ID# Section#
Reg.ID# Section#
Reg.ID# Section#
Reg.ID# Section#
The following class(es) have been cancelled: (No processing fee charged)
Units
Reg.ID# Section#
Reg.ID# Section#
I am requesting a refund for the Associated Student Activity Fee. (Must be approved by ASB. No processing fee charged)
I obtained a fee waiver after I paid for may classes: (One-time processing fee charged per term)
Other, Please state reason:
I would like to make a donation of $ to the SJECCD Foundation for (check one):
Or
Student Signature Date Signed
Credit due $ Date:
Processing fee -
Transfer to
Money holds - ( )
Request turned in after deadline.
Total Refund: $ No credit balance: reason(s) circled*
*Classes dropped after deadline
Remarks: *Added additional classes
*Transferred $__________to__________
Received by:
Classes Dropped?
Date Sent to District Offices:
Approved by:
Denied by:
Note: Refund requests received after the deadline must be accompanied with a General Petition and documentation. Check Schedule of Classes for
refund information/deadlines. Please allow 6 to 8 weeks for processing of payment after deadline.
Notice: There is a one time $10 processing fee per semester.
Dept/Crse#
Dept/Crse#
Apt. #
First
Rev 04/2020
FOR OFFICE USE ONLY
Student Scholarships
College Support
Verified By
Dept/Crse#
Dept/Crse#
Dept/Crse#
Dept/Crse#
Zip
City
Telephone
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Refund.request.form Please Print: SID Or M.I. Number & Street (San Jose City College)

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Completed 26 July 2020

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