LAFAYETTE PARISH SCHOOL SYSTEM CHILD NUTRITION SERVICES STUDENT MEAL ACCOUNT REFUND / TRANSFER FORM COMPLETE 1 FORM PER STUDENT VENDOR #

RMB

DATE

SCHOOL

STUDENT NAME REFUND AMOUNT $

STUDENT ID# REASON FOR REFUND (Check One) Out of parish or state transfer Status change (select one) CEP School Lunch from home Graduation Homeschool Transfer to sibling account

Full Pay to Free

Full Pay to Reduced

Reduced to Free

Sibling Name Sibling School Sibling ID #

******PLEASE PRINT****** PARENT / GUARDIAN NAME MAILING ADDRESS Please use fowarding address if student is moving CITY

STATE

PHONE

ZIP

CELL

Parent / Guardian Signature

Date

Alicia Motes, Meal Benefits Coordinator

Date

Renee Sherville, Director

Date

Submit completed form by one of the methods below to Child Nutrition Services: Email: [email protected] | Fax: (337) 521-7388, ATTN: Alicia Motes Mail: Child Nutrition Services, ATTN: Alicia Motes, 101 Evans Lane, Lafayette, LA 70506 Please allow 6 to 8 weeks for processing. Revised 07.13.2017