NUTRITION SERVICES DEPARTMENT
5050 Barranca Parkway, Irvine, CA 92604
Phone: (949) 936-6520
· Fax: (949) 936-6529 · Email: nutrition@iusd.org
Refund/Transfer Request
Purpose of submitting this form:
□Requesting a refund
□Requesting funds be transferred to a sibling
□Requesting funds be transferred to Nutrition Services Good Samaritan Account for
students in need
Student’s School: ___________________________________________________________________
Student’s Name: ___________________________________________________________________
Student’s Permanent ID #: __________________________________________________________
(If Transfer) Transfer to Sibling:
Sibling’s Name: ____________________________________________________________________
Sibling’s Permanent Student ID #: ___________________________________________________
Sibling’s School: ____________________________________________________________________
(If Refund)
Make Refund Check Payable To: ___________________________________________________
Mail Refund Check to: _____________________________________________________________
City, State, Zip: ____________________________________________________________________
Phone Number where you can be reached: ________________________________________
Reason for Transfer/Refund: ________________________________________________________
___________________________________________________________________________________
Please note that a student’s meal account money is automatically carried over to the
next school year EXCEPT after completion of 12
th
grade. If your child will no longer be
attending a school within the Irvine Unified School District, please notify our office. No
refund is required for maintaining the meal account balance through the next school
year.
___________________________________
(Printed Name of Parent/Guardian)
___________________________________
(Signature of Parent/Guardian)
Date: _____________________________
Received: _________
Processed: ________
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