Refund Request LOA/Disability Only

River Campus
MAIL: 500 Joseph C. Wilson Blvd.
Rochester, NY 14627

GPS/MAPS: 252 Elmwood Ave.
Rochester, NY

Date:
Name:
Employee ID:
Payroll Frequency:
Address:
City/State/Zip:
Work Phone:
Home Phone:
Email:
Disability Dates:
Reason for Refund:
BELOW BOXES ARE FOR ADMINISTRATIVE USE ONLY:
Date Contacted Person:
Contacted Via:
Amount Refunded and Date:
Refunded Via:
Comments:
Authorized Signature:
Director Signature:

Parking & Transportation Services