Food & Nutrition Services
Refund Request Form
PAYEE NAME*
AMOUNT $
(Leave blank if unknown)
STUDENT NUMBER
STUDENT NAME*
SCHOOL NAME*
Choose a SCHOOL NAME
Cascade High
Cedar Wood
Eisenhower
Emerson
Everett High
Evergreen
Forest View
Garfield
Gateway
Hawthorne
Heatherwood
HM Jackson
Jackson
Jefferson
Lowell
Madison
Mill Creek
Monroe
North
Penny Creek
Sequoia
Silver Firs
Silver Lake
Tambark Creek
View Ridge
Whittier
Woodside
PAYEE ADDRESS*
Phone:*
CITY*
STATE
ZIP*
REASON FOR REFUND REQUEST
Please select what you would like us to do with the money left in your account. If no box is checked, then a check will be sent to the payee at the address listed above.
FULL REFUND TRANSFERRED TO:
STUDENT`S NAME
SCHOOL NAME*
Choose a SCHOOL NAME
Cascade High
Cedar Wood
Eisenhower
Emerson
Everett High
Evergreen
Forest View
Garfield
Gateway
Hawthorne
Heatherwood
HM Jackson
Jackson
Jefferson
Lowell
Madison
Mill Creek
Monroe
North
Penny Creek
Sequoia
Silver Firs
Silver Lake
Tambark Creek
View Ridge
Whittier
Woodside
STUDENT NUMBER
or birthday if ID is unknown
FULL REFUND ISSUED TO THE PAYEE AT THE ADDRESS LISTED ABOVE
DONATE TO SCHOOL (To support students who need assistance paying for school meals)
By checking the box below you acknowledge that Autopay with My Payments Plus has been turned off for this student or that it is not applicable.
Autopay on My Payments Plus is turned off or this is Not Applicable*
Full refunds will be issued in 4-6 weeks. Transfer and donation requests will be processed within 48 hours of receipt. Once completed, use the submit button below. Contact Food & Nutrition Services at 425-385-4380 or email foodservices@everettsd.org for questions.
FOR FOOD & NUTRITION AND ACCOUNTING USE ONLY
ACCOUNT CODE (BUDGET)
ORIGINAL RECEIPT (R #)*
RECEIVED BY
DATE
AUTHORIZED BY
DATE
ACCOUNTING NOTES
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