Safe Rides Cash Back Form

Safe Rides Cash Back Form

Hello Hornet! Complete the following form to request cash back for an eligible rideshare trip or vehicle safety inspection. The last day to submit a Safe Rides cash back form for the Fall 2021 semester is December 22.
Student Information
Name *

First Name Last Name
Sac State Email Address *
Please enter a valid @csus email address
Student ID Number *
Upload One Card (Student ID Card) Image *

Please upload an image of your current Sac State student One Card.
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Mail or hold cash back check for pickup? *

Mail my check
Approved Reimbursement Amount
What is your current mailing address?

Street Address

Street Address Line 2

City State

Zip Code

What type of service are you requesting cash back? *

Rideshare service (Uber, Lyft, taxi rides) Vehicle Safety Inspection (SMOG checks, vehicle safety inspections)

Trip Details

Enter in the following details about your rideshare trip below.
Debit/Credit Card Image

Upload an image of your debit or credit card that was used to pay for your rideshare trip. Please block out the first 12 numbers on the card, leaving only the last four digits showing on the image. The debit/credit card must be issued in your name.
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Upload Rideshare Trip Receipt

Upload a rideshare trip receipt. Receipt must show your name, trip route, date of trip, total cost of trip and the last 4 digits of your debit/credit card. Trip receipts are typically available in your rideshare app. 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.
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Vehicle Safety Inspection Details

Enter in the following details about your receipt below.
Debit/Credit Card Image

Upload an image of your debit or credit card that was used to pay for your rideshare trip. Please block out the first 12 numbers on the card, leaving only the last four digits showing on the image. The debit/credit card must be issued in your name.
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Upload SMOG or Vehicle Safety Inspection Receipt/Invoice

Upload a vehicle safety inspection receipt/invoice. Receipt must show your name, the name of the business, the type of service performed (SMOG or inspection service), total cost including tax and the last 4 digits of your debit/credit card.
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Student Information