Student Refund Form
Name:
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H Number:
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Date:
CUC Email:
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Cell phone:
Address:
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City:
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State:
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Zip:
Type of refund: If you have a credit balance, please consider donating to the Student Assistance Fund.
Full credit balance
Full credit balance, less a donation to
Partial credit balance, plus a donation
the Student Assistance Fund to the Student Assistance Fund
Donation amount: ______________ Refund amount: ______________
Donation amount: ______________
Refund Method:
Direct Deposit
(fill in account info below)
Pick Up at Student Business Services Office
Mail to Above Address
This form must be submitted no later than the end of business day Friday to receive a check the following Friday, if funds are
available. Checks will be available for pick up after 2 p.m. at the Cashier’s desk. Direct deposits will generally be credited to the
account on the same day that paper checks are available for pick up.
DIRECT DEPOSIT ACCOUNT INFORMATION (for direct deposit only)
Please deposit the credit balance specified above into the following account:
Name of Bank
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City
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State
Account Type: Checking Savings
Bank Transit Routing Number (must be 9 digits):
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Account Number (amount of digits vary):
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I understand that I am responsible to check with my selected banking facility to determine that they will receive direct deposit refund funds for
my account, and that I am responsible for any bank charges made to my account for this service by my bank. It is my responsibility to ensure
the accuracy of the bank information indicated above. I further understand that it is my responsibility to notify Concordia University Chicago
in writing of any changes to the information above, and to provide a reasonable amount of time for the changes to be made. My failure to do so
may result in a delay of my refund. If a direct deposit transaction is rejected for any reason, I understand that a refund will be re-issued by check
unless I provide updated account information in writing. Finally, I understand that the University reserves the right in all cases to issue a refund
in the form of a check.
By signing below I acknowledge that I agree to receive either the refund amount specied above or the full credit balance on my account. If
additional credit balance remains on the account after this request is processed, I agree for the remaining credit balance to be applied toward
future tuition and/or fee charges. I also agree to complete and submit a new refund request form for each refund request as this form will only be
processed one time.
>> Student Signature:
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Date:
IMPORTANT NOTE! This student refund check is being provided to you based upon your student tuition account balance at the
time of issuance of this check. There may be other expenses that are assessed to your account after this date, i.e. bookstore
voucher purchases, phone bills, parking tickets, additional tuition, and financial aid returned due to drop of a class, etc.
YOU WILL BE RESPONSIBLE FOR THOSE CHARGES AT THAT TIME.
SUBMIT COMPLETED FORM TO CUC STUDENT BUSINESS SERVICES
Fax 708-488-4293 | Email: refunds@cuchicago.edu
NOTE: Emailed requests must come from a valid CUC email account in order to be processed.
OFFICE USE ONLY
Date received: Date refund issued to student: SBS Representative:
Office of Student Business Services | rev 3/20
click to sign
signature
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