Security Deposit Release Form (Form D-5)

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TO BE COMPLETED BY STUDENT
STUDENT ACCEPTANCE*
I, the undersigned, understand the refund policy and agree with the balance refund as calculated above and to pay any outstanding amounts owing. I have removed all my belongings from the dormitory and will not expect J. Addison to store or be responsible for any items that may have been left behind.

Student First Name Student Last Name
Student Signature*
Date*
MM slash DD slash YYYY
TO BE COMPLETED BY DORMITORY STAFF
DORMITORY STAFF*
The Dormitory staff confirms that the room is void of any damages and J. Addison will release the student’s security deposit in cash back to the student, unless a different method of refund was indicated on the student’s Dormitory Residence Application (form D-1).

Dormitory Staff First Name Dormitory Staff Last Name
Dormitory Staff Signature*
Date*
MM slash DD slash YYYY
Hidden
TO BE COMPLETED BY ACCOUNTING

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J. Addison School