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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.
  4. Google Chrome or Mozilla Firefox recommended when completing the form.

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 serious medical condition or injury beyond the student's control, the student should NOT request a special circumstances refund. Instead, the student must complete a Medical Withdrawal Petition 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
Date






Received by
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  • If you have any problems completing this form, please contact fmsupport@csulb.edu.
Try to display a printer friendly version again.Revision Date: 06/2016