UF&S::FORMS::Refund Request Form (Non-Disability)

Facilities Forms

Refund Request Form (Disability)

Fill out all blanks and submit. Please allow 2-3 pay cycles for refund to be processed.
Please do not submit for Paid Family Leave (PFL). PFL does not qualify for a refund.

First Name:

Last Name:

Employee ID:

Payroll Frequency:

Address Line 1:

Address Line 2:

City/State:

Zip:

Work Phone:

Phone Number:

Your Email:

Disability Start Date:

Disability End Date:

Reason for Refund:

University Facilities and Services

Facilities and Services

Refund Request Form (Disability)