Refund Request Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{company_phone}}

Email: {{company_email}}

Website: {{company_website}}

Refund Request Form

Date: {{request_date}}

Request Number: {{request_number}}

Customer Information

Full Name: {{customer_full_name}}

Address: {{customer_address}}

Phone Number: {{customer_phone}}

Email Address: {{customer_email}}

Account Number (if applicable): {{customer_account_number}}

Purchase Details

Item/Service Purchased: {{item_service_description}}

Date of Purchase: {{purchase_date}}

Order/Invoice Number: {{order_invoice_number}}

Amount Paid: {{currency}} {{amount_paid}}

Reason for Refund Request

Please provide a detailed explanation for your refund request:

{{reason_for_refund_details}}

Supporting Documentation (e.g., receipts, photos, defect reports, communication logs):

{{supporting_documentation_list}}

Refund Method Preference

Please indicate your preferred refund method:

☐ Original Payment Method (e.g., credit card, bank transfer)

☐ Store Credit

☐ Other (please specify): {{other_refund_method}}

If original payment method is not possible, please provide alternative bank details for direct deposit:

Bank Name: {{bank_name}}

Account Name: {{account_name}}

Account Number: {{account_number}}

Sort Code/SWIFT/IBAN: {{sort_code_swift_iban}}

Declaration and Authorization

I, {{customer_full_name}}, certify that the information provided in this form is true and accurate to the best of my knowledge. I understand that false statements may result in the rejection of my refund request. I authorize {{company_name}} to process my refund as per the details provided.

For Official Use Only

Date Received: {{official_date_received}}

Processed By: {{official_processed_by}}

Refund Approved: ☐ Yes ☐ No

Approval Date: {{official_approval_date}}

Refund Amount: {{currency}} {{official_refund_amount}}

Reason for Rejection (if applicable): {{official_rejection_reason}}

Notes: {{official_notes}}

Signature Block

___________________________

Customer Signature

Date: {{customer_signature_date}}

___________________________

Authorized Company Representative Signature

Date: {{company_signature_date}}