CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS
REQUEST FOR SPECIAL CIRCUMSTANCES REFUND FORM
Submit t
o:
Cashier’s Office
One Univ
ersity Drive – Sage Hall
Camarillo, CA 93012
Phone: (805) 437-8810
Fax: (805) 437-8900
______________________
__________________________________________________
Informati
on
Name: CSUCI ID #:
Street Address:
Cit
y, State, Zip
Hom
e Phone: Work Phone: Cell Phone:
Semester:
Email:
Written Explanation of Request
Title V of the State Education Code has specific allowances for approval of refunds after the published deadline. In the space provided
below, please provide a detailed explanation why you are requesting a refund or reversal of outstanding charges past the deadline.
You must provide all documentation that supports your request for a refund. Incomplete documentation will result in returning the request
for additional information.
Requestor Signature______________________________ Date _______________________________
Received by Cashier Office Signature_______________ Date _______________________________
________________________________________________________________________________
Request Approved:
Request De
nied:__________________________________________________________
