TYPES OF CONTRACTS

CLAIMS VERIFICATION BOARD

ROUTING FORM

PURPOSE: To give the person seeking a refund or repayment a procedure which lays out what he is supposed to do.

NOTE TO THE CLAIMANT: This form is provided to assist you. It is designed so that you can take it, in hand, and do the steps and see each person in the order listed. This will ensure that each of the steps of your claim is swiftly expedited. It is your responsibility to see that this form is properly executed and filled out and mailed to the Claims Verification Board.

If you need any help or guidance in getting this routing form done, please consult the org Keeper of Tech (or LRH Communicator) who will help you.

DIRECTIONS:

1. SIGNING: When a step is done, you place your initials on the line to the right of the step.

2. ALTERNATE TERMINALS: If a post listed on this form is not filled or the person is absent from post, the senior or alternate terminal does the actions as if he were the post holder and marks the appropriate box.

1. CLAIMANT

a . Read the PURPOSE, NOTE and DIRECTIONS above.

b. Fill in (PLEASE PRINT CLEARLY):

NAME ___________________________________________________________

ADDRESS _________________________________________________________

STATE/PROVINCE ______________________ COUNTRY ___________________

POSTAL CODE __________________________PHONE _____________________

AMOUNT OF REPAYMENT REQUESTED ___________________________

AMOUNT OF REFUND (IF ANY) REQUESTED ___________________________

TOTAL AMOUNT REQUESTED ___________________________

NAME OF ANY FSM(S) WHO FSMed YOU FOR ANY SERVICE(S) YOU ARE

REQUESTING A REFUND/REPAYMENT FOR:

_________________________________________________________________

c. Carefully read and ensure you fully understand the attached "Claimant

Information Sheet."

d . Go to the Chaplain in Division 6.

Date: ______ Time: ______

2. CHAPLAIN DIVISION 6

or Ruds Officer _____ or Ruds Auditor or ____Other

a. Receive an interview from the Chaplain to determine the exact reason for requesting a

Refund/Repayment. (HCO PL 6 May 84, ARC BREAK PROGRAM, ADDITIONAL DATA).

b. Receive a metered action as arranged by the Chaplain. (HCO PL 9 Nov. 74R, REFUNDS

AND REPAYMENTS)

c. When all handlings are complete and if you no longer wish a Refund/Repayment,

terminate this routing form per the INCORRECT/UNCOMPLETABLE ROUTING

FORM instructions at the end.

d. If you still wish to receive a refund or repayment, get a signed statement from the

Chaplain on what actions have been done and attach it to this Routing Form.

e. Ensure you have all invoices, cancelled checks, and receipts or good xeroxes or

Photostats thereof.

f. Write out (in duplicate) and sign the following statements in front of a notary public

and attach them to this Routing Form:

1. “I have not already been given a refund or repayment on this matter.”

2. “I understand that I cannot, by reason of refund or repayment, obtain further service from orgs, missions or individuals and may not have upper level services."

3. “I understand there is an administrative charge for the claim.”

g. Bring the signed statements and your copies of all invoices, cancelled checks, and

receipts or good xeroxes or photostats to the Treasury Secretary.

Date: ______ Time: ______

3. TREASURY SECRETARY DIVISION 3

or ____ Board Finance Officer or ____ person acting as Treas Sec

a. Present your signed statements and all required documents as covered in the

Claimant Information Sheet to the Treasury Secretary.

b. Have the Treasury Sec verify in your accounts file that there is no debit or corrective

invoice that modified your documentation and that it is all correct. Get a signed attest

from the Treasury Sec and attach it to this Routing Form. _______

Date: ______ Time: ______

4. TECHNICAL SECRETARY DIVISION 4

or ____ Dir Tech Services or ____ person acting as Tech Sec

a. Get a statement from the Technical Secretary that the service has not been delivered, or how much has been delivered and attach it to the Routing Form.

Date: ______ Time: ______

5. QUALIFICATIONS SECRETARY DIVISION 5

or ____ Dir Review or _____ person acting as Qual Sec

1. Statement from the Qualifications Secretary that the person has received or has refused correction.

a. Get a signed statement from the Qual Sec that you have received or refused correction.

Date: ______ Time: ______

6. FLAG BANKING OFFICER (FBO) DIVISION 7

or ____ person acting as FBO

a . Have the FBO verify that your check(s) for the service(s) were never cancelled and that

they were collected, or that the money, if cash, was actually received and not returned.

Have him sign a statement to this effect and attach to the Routing Form.

b. Inform the FBO it is mandatory to set aside a sum of money equivalent to the claim in

the CVB Account or in a special account to hold it for any future payment if the claim is

fully verified by the CVB. Get from the FBO an attest that the money has been set aside. ______

c. Put the Invoices, cancelled checks, receipts, the statements from the Treasury Sec, Tech

Sec, Qual Sec and FBO and this routing form in a n envelope.

d. Affix the correct postage to the envelope and mail it to:

Claims Verification Board

Church of Scientology International

6331 Hollywood Boulevard, Suite 801

Hollywood, California 90028-6300, USA

(Note: Do not: send by registered mail as this violates Church policy, HCO PL 26 May 65 II, COMMUNICATIONS, REGISTERED MAIL.)

Date: ______ Time: ______

7. CLAIMS VERIFICATION BOARD

a . Process the claim per Claims Verification Board policies.

b . If approved, work out the administrative charge.

AMOUNT: _______________________

c. Inform both tile claimant and the FBO by mail that the claim has been approved

and what the administrative charges are.

d. If the claim is disapproved, inform in writing both the FBO and the claimant.

Include instructions on what needs to be done to get the approval, if this is the

case.

e . Send the routing form back to the claimant.

Date: ______ Time: ______

8. CLAIMANT

1. Upon return of the routing form, read any communication included from the Claims Verification Board.

2. Take the routing form and any despatches from the Claims Verification Board and go see the Ethics Officer.

Date: ______ Time: ______

9. ETHICS OFFICER DIVISION 1

or ____ Dir of Inspection & Reports or _____ HAS

a . Sign the Release, Waiver and Writ of Expulsion per HCO PL 9 Nov. 74R, REFUNDS AND REPAYMENTS.

b . Have the Ethics Office file the Waiver in Valuable Documents for the org's protection.

c. Have the Ethics Officer sign his attest below that you have filled out and signed

the Release, Waiver and Writ of Expulsion and they are now filed in Val Docs.

ETHICS OFFICER ATTEST: _______________________________________

Date: ______ Time: ______

10. TREASURY SECRETARY DIVISION 3

or ____ Board Finance Officer or ____ person acting as Treas Sec

a . Show the Treasury Secretary the Ethics Officer attest at step 9b above.

b. Request that the Treasury Secretary disburse the amount authorized by

CVB for the refund/repayment.

c. Hand over the copy of this Routing Form to the Treasury Secretary.

d. Treasury Sec to send the administrative charge to the Claims Verification Board. ______

e. Check for the name(s) of the FSM(s) who selected the claimant. Despatch the FSM I/C

with the details of the refund/repayment, and ensure that the FSM(s) is/are handled per

HCO PL 5 Apr. 79 I, FSM PENALTY FOR REFUNDS, REPAYMENTS AND BOUNCED CHECKS. ______

f. Take the completed Routing Form to HCO and have it filed in Val Docs which is the final step of this Routing Form.

Date: ______ Time: ______

END OF ROUTING FORM

SCIENTOLOGY, FLAG, HCO and LRH are trademarks and service marks owned by Religious Technology Center and are used with its permission.

ATTACHMENT

CLAIMANT INFORMATION SHEET

This form is provided to facilitate smooth and eventual satisfactory handling of Refund and Repayment requests. It outlines the procedure one uses in obtaining the refund or repayment being requested. Experience in handling both proper and faulty claims over the years has helped to develop this system.

It is good policy to ensure that claims are swiftly expedited. It helps the claimant and it helps the organization.

A REFUND IS A RETURN OF MONIES AFTER SERVICE CLAIMED WITHIN 3 MONTHS.

A REPAYMENT IS A RETURN OF MONIES WITHOUT THE SERVICE BEING TAKEN.

Over the years it has been found that many people applying for refund or repayment discover that they do not want them. The reasons are many and varied, but few people really wish to cut themselves off from the help the Scientology religion offers. If, while in the process of obtaining your refund or repayment, you decide that you do not wish to continue with it, please immediately inform the Chaplain or whoever is helping you get through this routing form.

The following information is given for your assistance.

1. NOTE: IF YOU HAVE JUST MADE YOUR DONATION BUT HAVE BEEN REFUSED AUDITING OR TRAINING BY A CHURCH, YOU DO NOT HAVE TO FILL IN THE FORM TO RECEIVE A RETURN OF YOUR DONATION. IT WILL BE REPAID AT ONCE. THE CHAPLAIN WILL ASSIST YOU WITH THIS.

2. No REFUND may be applied for after three months from the end of the last service rendered. This means that a refund applied for three months after the end of an intensive's last auditing session or last day of attendance on a course may not be granted.

3. YOU, THE CLAIMANT, MUST MAKE EVERY VISIT YOURSELF, WITH FORM IN HAND, TO THE PERSON/POST GIVEN ON THE ROUTING FORM. This is to help you and the organizational staff in expediting your request.

4. There have been many faulty claims received, so please make sure your information is clear and accurate. Such accurate and correct information attached to your claim will aid the Church in speedily processing your claim. Not having the correct information can complicate the process and slow your claim.

6. In doing this routing form, be sure to fill in the form and the attachments in duplicate. When you have completed the routing form, give a copy to the Finance Enforcement Officer (or FBO) for your accounts file in the org. Put the original (ensuring it is very legible) in a package and send it to the Claims Verification Board.

7. The documents that are required by the Claims Verification Board, to be included in the self-addressed envelope, are listed here for your convenience:

1. Invoices, cancelled checks and receipts or good xeroxes or photostats thereof.

2. A copy of your up-to-date account statement from the org.

3. Written and signed statements from all staff members you visit on the routing form explaining what actions they took with you.

4. A written statement notarized, that no refund or repayment has already been given on this matter.

5. A statement from the Technical Secretary that the service has not been delivered, or, how much has been delivered.

6. A statement from you stating you understand that by reason of refund or repayment, you cannot obtain further service from orgs, missions or individuals and may not have upper level services.

7. A statement that you understand that there is an administrative charge for processing the claim. (This charge will not exceed 3% of the claim.)

2. The Claims Verification Board has been set up by the Church to verify that claims meet all policy requirements and to see that claims are actually processed correctly and swiftly. The procedure enables you to gather all the necessary data in a speedy fashion and present it in a readily understood form. In this fashion, you do not have to rely on others for the completion of your claim.

CLAIMS VERIFICATION BOARD SECRETARY

Unpublished work: — 1988, 1991, 2006 CSI. All Rights Reserved. SCIENTOLOGY is a trademark and service mark owned by Religious Technology Center and is used with its permission.