Fee Refund Request

Please complete all requested information

Account Number *

Accountholder Name *

Accountholder Address *

City *

ZIP Code *

Daytime Phone Number *

Evening Phone Number *

Please specify the reason you are requesting a fee refund:

Charge under $10.00: I understand this is a one-time courtesy.

Merchant/Transaction Error: Please explain below.

Explanation

Fraudulent Transaction(s): Please provide detail below.

Transaction Detail

Supervisor review for additional fee refunds: Please explain below.

Explanation

Other

Explanation

NOTE: Fee refund requests will be reviewed within 24 business hours.

By checking this box, I acknowledge all of the information listed above is accurate to the best of my knowledge and I submit this fee refund request to be processed.

Please enter name of Accountholder *

FOR OFFICE USE ONLY

Approved

Denied

By employee/supervisor

Comments

Thank You