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California State University, Long BeachCalifornia State University, Long Beach

Request for Special Circumstances Refund


INSTRUCTIONS:


1. Complete the form and use the button below to display a printer friendly version.

2. Print the "Printer Friendly Version" of the form.

3. Return the form with signatures to Student Financial Services at BH-155.


Fields with * are required.

APPLICANT INFORMATION

REFUND DETAILS * I am requesting a Special Circumstances Refund in the amount of $
THE REASON








When a refund is requested due to a physical disability, the student should NOT request a special circumstances refund. Instead, the student must complete a Medical Withdrawal Request/Statement of Disability form obtainable at Enrollment Services BH-101. Refunds will be calculated on a prorata basis. Please refer to the Schedule of Classes refund section.

My signature on this application acknowledges that I have received, read and understand the policies and procedures for filing this application.

Student Signature
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