Refund Request Exhibit

Form Instructions

1. Select the date, from the drop-down calendar, the form was prepared
2. Enter the payee's full name
3. Enter the complete mailing address, including street, city, state, and zip code
4. Enter a reason for the refund request
5. Table (a header row, six columns, and five rows for data entry)
• Column 1 - Enter the Department Reference Number
• Column 2 - Enter the four (4) digit business area number
• Column 3 - Select the cost object type from the drop-down list. Options include: Cost Center, Internal Order, or Work Breakdown Structure
• Column 4 - Enter the cost object number
• Column 5 - Enter the eight (8) digit general ledger account number
• Column 6 - Enter the grant number (if appropriate)
• Column 6 - Enter the amount to be charged to the cost object
• Total - This is a calculated field. No entry necessary
6. The form initiator must provide their digital ID