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Request for Refund of Account Balance

Required

Please complete the form below. The requestor must be a parent or guardian. For assistance, please call the Child Nutrition Office (CNO) at 918-272-8034.

 

Must contain a date in M/D/YYYY format
Student's Namerequired
First Name
Last Name
Must contain only numbers
Requestor's Namerequired
First Name
Last Name
Ex: 1234 N. Main Street, Owasso OK 74055 (please be sure to include your complete address)
In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all programs.) Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, and American Sign Language) should contact the responsible State or local Agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a complainant should complete Form AD-3027, USDA Program Discrimination Complaint Form, which can be obtained online, at https://www. ascr.usda.gov/sites/default/files/USDA-OASCR%20PComplaintForm-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or fax: (833) 256-1665 or (202) 690-7442; email: program.intake@usda.gov. This institution is an equal opportunity provider.