Refund Request Form

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

Refund Request Form

Date of Request: {{request_date}}

Reference Number (if applicable): {{reference_number}}

Customer Information

Full Name: {{customer_full_name}}

Contact Number: {{customer_contact_number}}

Email Address: {{customer_email_address}}

Billing Address: {{customer_billing_address}}

Product/Service Details

Product/Service Name: {{product_service_name}}

Date of Purchase: {{purchase_date}}

Purchase Price: {{purchase_price}}

Quantity: {{quantity}}

Reason for Refund Request: {{reason_for_refund}}

Please provide a detailed explanation of the issue: {{detailed_explanation}}

Payment Information

Original Payment Method: {{original_payment_method}} (e.g., Credit Card, EFT, Cash)

Bank Name (for EFT refunds): {{bank_name}}

Account Holder Name: {{account_holder_name}}

Account Number: {{account_number}}

Branch Code: {{branch_code}}

Swift Code (for international refunds): {{swift_code}}

Supporting Documentation

Please attach copies of the following documents to support your request:

- Proof of Purchase (e.g., sales receipt, invoice): {{proof_of_purchase_attached}} (Yes/No)

- Product/Service agreement (if applicable): {{product_agreement_attached}} (Yes/No)

- Any other relevant documentation: {{other_documentation_attached}} (Yes/No)

Declaration

I, {{customer_full_name}}, declare that the information provided in this Refund Request Form is true and accurate to the best of my knowledge. I understand that false information may result in the rejection of my refund request.

I consent to {{company_name}} processing my personal data for the purpose of fulfilling this refund request.

Signature: __________________________

Date: {{declaration_date}}

Internal Use Only

Date Received: {{internal_date_received}}

Processed By: {{internal_processed_by}}

Refund Approved: {{internal_refund_approved}} (Yes/No)

Refund Amount: {{internal_refund_amount}}

Date Refund Processed: {{internal_date_refund_processed}}

Notes: {{internal_notes}}

Signature Block

Customer Signature: __________________________

Date: {{customer_signature_date}}

For {{company_name}}:

Authorised Representative Signature: __________________________

Name: {{authorised_representative_name}}

Title: {{authorised_representative_title}}

Date: {{authorised_representative_date}}