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[null,"Name:      ",null,null,null,null,"SU/Vendor \"9\" number:"]
[]
[null,"Address: "]
[]
[]
[null,"Reason for Refund:"]
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[null,"Refunds are made for cash or check payments only.  "]
[null,"Include Bursar receipt showing payment deposit."]
[null,"Credit card payments must be credited back to the credit card used for payment."]
[]
[]
[null,"DESCRIPTION","INDEX","FUND","ORG","ACCT","PROG","ACTV",null,"AMOUNT"]
[]
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[null,null,null,null,null,null,null,"TOTAL REQUESTED"]
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[null,"Signature of Payee ______________________________________________"]
[null,"Approved by Department Head or Dean ______________________________"]
[null,"Approved by Vice-President, if required: ______________________________",null,null,null,null,"Date: "]