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 by seeing 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 Chaplain who will help you.
DIRECTIONS:
SIGNING: When a step is done, you place your initials on the line to the
right of the step.
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 _________________________________________________________
CITY ______________________ STATE/PROVINCE ______________________
COUNTRY _________________ POSTAL CODE _________________________
PHONE ___________________ E-MAIL ______________________________
AMOUNT OF REPAYMENT REQUESTED ___________________________
AMOUNT OF REFUND (IF ANY) REQUESTED ___________________________
TOTAL AMOUNT REQUESTED ___________________________
NAME OF ANY FSM(S) WHO SELECTED 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 by turning it over to the Chaplain for filing.
d. If you still wish to receive a refund or repayment, get a signed statement from
the Chaplain on what actions have been taken with you and attach it to this
Routing Form.
Date:
________ Time: ________
3.
DIRECTOR OF SPECIAL AFFAIRS DIVISION 7 or
____ acting DSA
a. Ensure you have all invoices, cancelled checks, and receipts or good xeroxes or
photocopies thereof.
b. Write out (in duplicate) and sign the following statements in front of a notary
public and attach one copy to this routing form and give the other copy to the
DSA:
“I have not already been given a refund or repayment on this matter.”
“I understand that I cannot, by reason of refund or repayment, obtain further service from orgs, missions or individuals and may not ever have upper level services."
“I understand there is an administrative charge for the claim.”
c. Bring the signed statements and your copies of all invoices, cancelled checks,
and receipts or good photocopies to the Treasury Secretary.
Date:
________ Time: ________
4.
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 to this effect and attach it to this Routing
Form.
________
Date:
________ Time: ________
5.
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: ________
6.
QUALIFICATIONS SECRETARY DIVISION 5 or
____ Dir Review or _____ person acting as Qual Sec
a. Get a signed statement from the Qual Sec that you have received or refused
correction.
7.
FLAG BANKING OFFICER (FBO) DIVISION 7 or
____ person acting as FBO
a. Request that 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. Request that he direct that the funds equivalent to the amount of your claim
be set aside by the Treasury Sec in the org“s CVB account and notify you
when it has been done.
Have the FBO attest that the above two steps have been done.
FBO Signature_______________________
8.
CLAIMANT
a. Make 2 copies of this Routing Form and all your invoices, cancelled checks,
receipts, the notarized statements, the written statements from those you have contacted per this Routing Form (Treasury Sec, Tech Sec, Qual Sec and FBO).
b. Give the DSA the originals of your Routing Form and documents for the org
Val doc files and so he can verify the package is complete. Keep one copy for
yourself.
c. Mail all the documents noted above along with a self-addressed
return envelope to the following address:
Claims Verification Board
Church of Scientology International
6331 Hollywood Boulevard, Suite 1200
Hollywood, California 90028-6300, USA
(Note: Do not send by registered mail as this violates Church policy:
HCO PL 26 May 1965 II, COMMUNICATIONS, REGISTERED MAIL)
Date:
________ Time: ________
9.
CLAIMS VERIFICATION BOARD
a. Process the claim per Claims Verification Board policies.
b. If approved, work out the administrative charge.
Amount:
_______________________________________
Indicate the amount to be refunded or repaid:
_______________________________________________
c. Inform the claimant by return mail that the claim has been approved,
stating the exact amount, less the administrative charges. Send copies to the
org Chaplain, FBO and DSA.
d. If the claim is disapproved, inform the claimant in writing with copies to
the DSA, FBO and Chaplain, stating why. Note what the claimant needs to
do to get the approval, if this is
the case.
e.
Return the routing form to the claimant .
Date:
________ Time: ________
10.
CLAIMANT
Upon return of the routing form, read any communication included from
the Claims Verification Board.
CONDITIONAL: If the claim was disapproved, handle per instructions.
Take the routing form and any dispatches from the Claims Verification
Board and see the Director of Special Affairs.
Date:
________ Time: ________
11.
DIRECTOR OF SPECIAL AFFAIRS (DSA) DIVISION 7 or
____ person acting as DSA
a. Sign the Release and Waiver per HCO PL 9 Nov. 74R, REFUNDS AND
REPAYMENTS and SPD 28 July 82R REFUNDS AND REPAYMENTS
WRIT
OF EXPULSION AND WAIVER.
b
.
Have the DSA give you a copy of your Writ of Expulsion. .
c. Have the DSA sign his attest below that you have filled out and signed
the Release and Waiver.
DSA ATTEST: _____________________________________________
Date:
________ Time: ________
12.
TREASURY SECRETARY DIVISION 3 or
____ Board Finance Officer or ____ person acting as Treas Sec
a
.
Show the Treasury Secretary the DSA attest at step 10c above.
b.
Receive from the Treasury Secretary the
amount authorized by C
VB
for
the refund/repayment and sign a receipt for the funds.
c. Hand over the Routing Form to the Treasury Secretary which ends your
actions.
THE NEXT 2 STEPS ARE DONE BY THE TREASURY SECRETARY
d. Send the administrative charge assessed to the Claims Verification Board.
e
.
Check for the name(s) of the FSM(s) who selected the claimant.
Dispatch
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.
THE FINAL 2 STEPS ARE DONE BY THE DSA
f. Make 3 copies of the Writ of Expulsion and mark it:
“ENTHETA
To Central Files
To Address
TO ETHICS DEAD FILES” (Ref: HCO PL 7 June 65 Entheta Letters and the Dead File, Handling Of.)
Route one copy to your org“s Central Files, one to IJC and one to the Central Addresso Officer Int.
g. Take the completed Routing Form and all original documents to HCO,
Department
3, to be filed in V
al
Docs.
Date:
________ Time: ________
END OF ROUTING FORM
CVB ROUTING FORM ATTACHMENT
CLAIMANT INFORMATION SHEET
This form is provided to facilitate smooth and eventual satisfactory handling of requests for return of donations. Experience in handling both proper and faulty claims over the years has helped to develop this system.
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 rapidly gather all the necessary data and present it in an easily understood form. In this fashion, you do not have to rely on others for the completion of your claim. It is good policy to ensure that claims are swiftly expedited: it helps you and it helps the organization.
Over the years it has been found that many of those who have applied for return of donations really do not want to go through with them. The reasons are many and varied, but few really wish to cut themselves off from the help the Scientology religion offers. By receiving a return of your donations, you will no longer be eligible for any Church services and will be expelled from the Church. If, while in the process of obtaining your return of donation, you decide that you do not wish to continue with it, please immediately inform the Chaplain so the appropriate steps can be taken to get you back on the road to spiritual freedom.
-----
A REPAYMENT is a return of donations without the service being taken.
A REFUND is a return of donations after service. 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.
In the past, there have been faulty claims received, so please make sure your information is clear and accurate. Accurate and correct information attached to your claim will aid the Church in speedily processing your request. Not having the correct information can complicate the process and only serve to slow the processing of your claim.
The documents that are required by the Claims Verification Board are listed here for your convenience:
Invoices, cancelled checks and receipts or good photocopies thereof.
Written and signed statements from all staff members you see on the routing form explaining what actions they took with you.
A notarized written statement that no refund or repayment has already been given on this matter.
A statement from you that you understand that by reason of refund or repayment, you may not again be processed or trained and may not ever, even if later reinstated, enroll for Grade VI, VII or any OT levels.
A statement that you understand that there is an administrative charge for processing the claim. (This charge will not exceed 3% of the claim.)
Keep all records and documents in order and very legible as you are doing this form, as you will be required to send them to the Claims Verification Board with a self-addressed envelope.
Before you receive a return of donations, you will be required to sign a Release and Waiver of any claims against the Church.
YOU, THE CLAIMANT, WITH FORM IN HAND, MUST SEE EACH PERSON/POST GIVEN ON THE ROUTING FORM AND DO THE SPECIFIC STEPS COVERED. This is to help you and the organizational staff in expediting your request.
CLAIMS VERIFICATION BOARD
SECRETARY
Unpublished work: — 1988, 1991, 2007 CSI. All Rights Reserved. SCIENTOLOGY is a trademark and service mark owned by Religious Technology Center and is used with its permission.