Refund Request Form
Division
FHS
LIB
PRS-Facilities/Classes (Wayne)
PRS-Sports (Jocelyn)
RENTAL/ACTIVITY INFORMATION
Last Name of Reservation Holder, or Participant
*
Reservation Confirmation #
Activity Transaction Receipt #
Date of Event, First Day of Activity
*
/
Month
/
Day
Year
Date
REFUND INFORMATION
Will a refund be issued to the reservation holder, or participant?
*
Yes, full refund is recommended to customer.
A partial refund is recommended.
Refund not recommended.
Amount of Refund to Reservation Holder, or Participant
Enter Dollar Amount of Refund
Reason for Withdraw or Refund from Program or Activity:
Is the Refund $500 or more?
*
Yes
No
Account(s)
*
DEPOSITS 1010-249000
FHS HP/CE RENTALS - 10105840-425210
FHS ADMIN FACILITIES - 10105899-425210
LIB FACILITY USE FEES - 10105699-425210
PRS RENTAL FACILITIES - 10105430-425210
PRS PARKS FACILITIES - 10105420-425210
PRS SPORTS FACILITIES - 10105435-425210
SECURITY FEES - 10102220-422045
Other
WITHHOLDINGS (CLAIM CHARGE)
Amount of Withholding (claim charge)
Reason for withholding:
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