BG Bucks Refund Request

BG1 Plus

112A Bowen-Thompson Student Union

Phone: 419-372-4127, Fax: 419-372-4364

www.bgsu.edu/bg1plus

Note: This form is used to request a refund of BG Bucks. This form is not used to request a refund of

Falcon Dollars or Bookstore Bucks. To inquire about Falcon Dollars, contact BGSU Dining. To inquire

about Bookstore Bucks, contact the BGSU Bookstore

Full Name:

BGSU ID:

Mailing Address:

Phone Number: BGSU E-mail

Please check one of the following reasons for your refund request::

I am graduating from BGSU as of ___________________________(Graduation Date)

I am withdrawing from BGSU as of __________________________(Withdrawal Date)

I will no longer be employed by BGSU as of __________________(Termination Date)

I am continuing with the University, however, I am requesting a refund of $__________ at this time.

Option only

available at the end of the Spring Semester.

If you are employed by BGSU and have a payroll deduction set up by the University, would you like to stop that?

Yes No

A $10.00 check processing fee will be assessed and deducted from the amount of your refund request. If the

balance on your BG Bucks account is below $10.00, you will not receive a refund.

Signature: Date:

Return this form to BG1 Card Services. Our contact methods are listed above.

For Office Use Only

BG Bucks Balance ____________________ Amount processed in BbTS _________________

Amount of Refund ____________________ Date processed in BbTS _________________

Payroll Deduction ____________________ Refund processed by _________________