25-26 ASI Safe Rides Cash Back Form

ASI Safe Rides Reimbursement Request Form

**10/2/2025 UPDATE: Due to a high interest in Safe Rides this semester, wait times may be increased.**
What is your name?*

First NameLast Name
CSUS Email*

Confirmation EmailVerify that the emails match.
Student ID Number*
Phone Number*

Area CodePhone Number

**DO NOT DELETE THESE QUESTIONS - THEY HOLD PREVIOUS YEARS' DATA.**
Card Used for Purchase of Safe Ride

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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
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Upload Bank Statement PDF that shows Student Name and purchase date

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Upload Rideshare Trip Receipt

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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
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Upload Smog check with students name on it

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

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Make sure the recipt is within this semester. Amount paid should be clear on the recipt Cancelof
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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

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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
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

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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

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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

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

Mail my check
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Step 1

I paid with my credit card.
Upload a picture of the credit card you used to pay.
Front of Card
Back of Card
File Upload

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I blocked the first 12 numbers.

Yes
I can see my name.

Yes
My photo is not blurry.

Yes
You only need to fill out one kind of payment method.

I paid with ApplePay/GooglePay/Zelle from bank account.
Upload the transaction from your bank statement and the top of the page where your name is shown.
Upload bank statement:
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I can see my name.

Yes
My transaction amount and date are shown.

Yes
You only need to fill out one kind of payment method.

Step 2

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

Only upload the Files needed for the reimbursement you are requesting.

Smog Check or Vehicle Inspection
Upload smog check or vehicle inspection receipt:

CA REAL ID
Upload DMV paper or electronic receipt:

Uber/Lyft Rides
Screenshot of Uber/Lyft ride:

Step 3

Mailing Address
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.
Upload Picture of OneCard

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Signature:*

Clear
Should be Empty:

ASI Safe Rides Reimbursement Request Form

**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

Upload a picture of the credit card you used to pay.

You only need to fill out one kind of payment method.

Upload the transaction from your bank statement and the top of the page where your name is shown.

You only need to fill out one kind of payment method.

Step 2

Scroll down until you find the right section for you.

Step 3

We will review your information and mail out a check.

LAST STEP:

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