S o u t h e r n   I l l i n o i s   U n i v e r s i t y

C a r b o n d a l e

Request for Refund of Student-to-Student Grant Fee

Name_________________________________  ID Number 

Semester_______________   Year_________

I request that the amount of the Student-to-Student Grant Fee be applied as a credit to my account.  I understand this request makes me ineligible to receive benefits from the Student-to-Student Grant Program.

_______________________________________________        ___________________

  Student Signature                                                      Date

Instructions:  This request must be received within the first two weeks of classes for the Spring/Fall semesters, or by the first week of the Summer semester.  You may either hand-deliver, mail or fax this form to the address of fax number listed below:   

Office of Records and Registration

Woody Hall, Room A-115

Mailcode 4701

Carbondale, IL  62901-4701

FAX: (618) 453-2915