Systems and Procedures
A Division of The Corporate Controller's Office
IN

REFUND REQUEST
FORM INSTRUCTIONS

Form Instructions

  1. Name and Address – Enter the payee’s full name and address.

  2. Reason for Request – Enter a reason for the refund request.

  3. Table (a header row, six columns, and five rows for data entry)


  4. Check is to be mailed – Check the appropriate box – Check is to be mailed or Check is to be held.

  5. The completed form is printed, signed, and dated. The individual’s title and department name are to be included.

Image of Exhibit A - Refund Request Form