25-26 ASI Safe Rides Cash Back Form v.3

ASI Safe Rides Reimbursement Request Form

This form closes after Finals Week of Spring Semester 2026.
Are your receipt dates between January 26th and May 17th, 2026?*

YesNo
Receipts from transactions outside of the dates will not be accepted (ASI Safe Rides eligibility policy #1).
Name*
OneCard #*
Physical OneCard*

Upload
ASI Safe Rides is for currently enrolled Sac State students. Cancelof
Contact Info

In case we need to follow up with you about your request. This allows us to quickly process reimbursements and update you on your status.
Sac State Email*

Confirmation EmailVerify that the emails match.
Phone #*

Receipts

Step 2: Upload receipts and verify information.
Multiple uploads allowed. We highly recommend uploading the Uber/Lyft receipt sent to your email, not the screenshot from the app.

Upload Uber/Lyft Receipts only

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Multiple uploads allowed. We highly recommend uploading the Amtrak receipt sent to your email.

Upload Amtrak Receipts only

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Multiple uploads allowed. *Bank statement required.

Upload DMV Receipts and Bank Statement only

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Proof of Payment

Step 3
Upload a picture of the credit card you used to pay.
Front of Credit Card - please cover the first 12 digits and leave the last 4 showing.

Upload

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Back of Credit Card - please cover the first 12 digits and leave the last 4 showing.

Upload

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The last 4 digits of my card match the last 4 digits on my receipt.

Yes, they do.No, they do not. I will need to upload a copy of my bank statement.
Apple Pay, Google Pay, and Zelle payments will require a bank statement that matches your receipt amount and timestamp.

Upload Bank Statement
Reimbursements without this verification will be denied. Cancelof

Mailing Address for Check

Step 4
Include your apartment/room/dorm/unit number.
Please complete this section carefully.

Mailing Address

Apartment, dorm, room, unit #

CityState / Province

Postal / Zip Code
Is this the same address you will be living at after Spring Semester 2026?*

Yes, please mail my check to this address.No, I plan to move after Spring Semester 2026. I will enter my permanent home address below.
Permanent Address (optional)

Mailing Address

Apartment, dorm, room, unit #

CityState / Province

Postal / Zip Code
I have submitted true and accurate information.*

Clear
Current Date and Time

MonthDayYear
DateHourMinutesAM/PM Option
Should be Empty:

Examples of Approved Receipts