TPP, TMS, FL Pre-Paid, Plus Loan & Cash Payments

Parental Refund Authorization Form Federal Direct Plus Loan

TO: Bethune-Cookman University (Office of the Bursar)

Student’s Name: ______

Student I.D. #: ______

Please Check One:

_____ Full (100%) Refund to Student The undersigned hereby requests and authorizes the entire credit balance on the account of ______be refunded to him/her. Student’s Name

_____ Partial Refund to Student The undersigned hereby requests and authorizes the amount of $______on the account of ______be refunded to him/her and $______Student’s Name be mailed to me at:

Name: ______

Address: ______

______

_____ No Refund to Student The undersigned hereby requests that no portion of the credit balance due to me from the account of ______be issued to him/her. Please mail full amount to me at: Student’s Name

Name: ______

Address: ______

______

Parent/Guardian Signature: ______Date: ______

STATE OF: COUNTY OF:

On ______before me, ______, (Date) (Notary) personally appeared ______, personally known to me (or proven to (Parent/guardian’s name) me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are in his/her/their authorized behalf of which the person(s) acts, executed the instrument.

WITNESS my hand and official seal.

Signature ______(Seal) Affidavit ______Known______Unknown______

ID Produced______Parental Refund Authorization Form Federal Direct Plus Loan

This Parental Refund Authorization Form (see reverse side) is designed for students who

are requesting refunds to be issued in the student’s name when the parent or guardian

signed for a Federal Direct Plus Loan.

If the Parental Refund Authorization Form is Not completed, the refund will automatically be issued to the

parent or guardian who signed for the loan.

This form must be Signed & Notarized and returned to:

Bethune-Cookman University Office of the Bursar Attn: (Your Staff Accountant’s Name) 640 Dr. Mary McLeod Bethune Boulevard Daytona Beach, FL 32114-3099

The form may also be faxed to the Bursar’s Office at 386-481-2512.

Please Note: If the parent or guardian signs this form and checks Full Refund or Partial Refund,

the parent or guardian is

authorizing the Office of the Bursar to issue a refund in the student’s name.

This Form is valid for only one (1) academic year and must be renewed for the following academic year.

Staff Accountants

If you have any questions concerning this form, please call your Staff Accountant.

Mrs. Pratima Mewar Ms. Jennifer Adjetey 386-481- 2032 386-481-2516 (A – I) (J – R) Ms. Mose 386-481-2535 (S-Z)