25-26 ASI Safe Rides Cash Back Form

ATTENTION, SAFE RIDES USERS:

This form is under maintenance and will reopen on Monday, September 8th!
Hold onto your receipts.

We will be reaching out to each of you when this form goes live on Friday, September 12th

Please fill out the information below if you would like us to remind you when this 2025-2026 Safe Rides request form is ready to complete.
What is your name?*

First NameLast Name
CSUS Email*

Confirmation EmailVerify that the emails match.
Student ID Number*
Phone Number*
**DO NOT DELETE THESE QUESTIONS - THEY HOLD PREVIOUS YEARS' DATA.**
Card Used for Purchase of Safe Ride*

Make sure the name on the card is your name and that only the last 4 digits of the card number is present. We do not need the whole string of numbers.
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DO NOT DELETE
Upload Bank Statement PDF that shows Student Name and purchase date

Cancelof
Upload Rideshare Trip Receipt*

Upload a rideshare trip receipt. Receipt must show trip route, a date that is within the current semester, total cost of trip and the last 4 digits of your debit/credit card. Trip receipts are typically available in your rideshare app or emailed to you after the ride. If you need help finding receipts, reach out to us. You may upload up to two rideshare receipts per Safe Rides cash back request form.
Cancelof
DO NOT DELETE
Upload Smog check with students name on it*

Upload anything releated to the smog check with your name on it
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Upload Receipt with last 4 Digits of the card on it*

Make sure the recipt is within this semester. Amount paid should be clear on the recipt
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DO NOT DELETE
What type of service are you requesting cash back?*

Rideshare service (Uber, Lyft, taxi rides)Vehicle Safety Inspection (SMOG checks, vehicle safety inspections)REAL ID refund (Once per student)
Upload Card Used For Purchase of Smog Check*

Make sure the name on the card is your name and that only the last 4 digits of the card number is present. We do not need the whole string of numbers.
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Enter in the following details about your rideshare trip below.

1. Card used for the ride (Please cover the first 12 digits)

2. Recipt of ride that clearly shows the last 4 digits of the the card used to pay
Upload REAL ID Receipt/Invoice/Bank statement*

Upload a REAL ID receipt/invoice. The receipt must be dated within the current semester. It must also include the total cost, including tax, and the last 4 digits of your debit/credit card. The receipt must be issued by CA DMV. If you do not have a receipt, upload a bank statement the charge from the DMV
Cancelof
DO NOT DELETE
Upload Card Used For Purchase of REAL ID*

Make sure the name on the card is your name and that only the last 4 digits of the card number is present. We do not need the whole string of numbers.
Cancelof
Upload bank statement for Apple Pay/Google Pay purchases*

Please make sure the screenshot includes your name and the Uber purchase that matches your receipt provided by uber.
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Mail or hold cash back check for pickup?*

Mail my check
DO NOT DELETE
Step 1

Proof of Payment
What credit card/bank account did you use to pay?
Front of Card
Back of Card
OR - Upload a copy of your bank statement for this specific transaction.
Upload portion of bank statement:
Step 2

Receipts
Scroll down until you find the right section for you.

Uber/Lyft Rides
Screenshot of Uber/Lyft ride:
Step 3 & 4
Mailing Address*
We will review your information and mail out a check.

Please *re-enter* your mailing address that is accurate as of Fall 2025. Don't forget to include your apartment #, room #, dorm #, or unit #, if applicable. Checks that are returned will not be re-issued.
Street Address

Apt#, Room #, Dorm#, Unit#

CityState

Zip Code
LAST STEP:

Verify that you are a currently enrolled Sac State student by uploading a picture of your OneCard.

Any false information or fraudulent claims will cause your request to be denied and possibly referred to The Office of Student Conduct (OSC) for investigation.

Please make sure the information you are submitting on this form is correct.
Cancelof
Signature:*

Clear
Should be Empty:

ATTENTION, SAFE RIDES USERS:

Hold onto your receipts.

We will be reaching out to each of you when this form goes live on Friday, September 12th

**DO NOT DELETE THESE QUESTIONS - THEY HOLD PREVIOUS YEARS' DATA.**

DO NOT DELETE

DO NOT DELETE

DO NOT DELETE

DO NOT DELETE

DO NOT DELETE

Step 1

What credit card/bank account did you use to pay?

OR - Upload a copy of your bank statement for this specific transaction.

Step 2

Scroll down until you find the right section for you.

Step 3 & 4

We will review your information and mail out a check.

LAST STEP:

DO NOT DELETE THESE QUESTIONS - THEY HOLD PREVIOUS YEARS' DATA.