Western Kentucky University 1906 College Heights Blvd. Bowling Green, KY 42101 Refund Voucher No.

Check will be mailed to this address: (Complete address required)      Name    Address Line 1    Address Line 2    City    State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY XX (International Addresses)    Zip

Check Payable To:

Account Number: Detail Code Index Fund Org Acct Prog Amount $ $ $ Total-> $

Social Security/Id Number      Type of Refund      Amount Subject to Refund   $ Deduct   $ Net Amount of Refund   $

Explanation of refund   Check to be returned to the Student Billing & Account Services.  For Student Billing & Account Services personnel only.

I certify that this voucher has been examined and that the proposed refund is correct.     Signed___________________________________ _______   Signed_______________________________ _______ Date               Student Billing & Account Services Date Department Preparing Voucher and Phone Number Print 3 copies. Keep one copy for your file and send the other 2 copies to the Student Billing & Account Services, Potter Hall, Room 208.