Inflation Relief Refund Request Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Employment Status

Have you previously received inflation relief from this program?

Requested Refund Amount (USD)

Reason for Refund Request

Upload Supporting Documents (such as proof of payment or hardship)

Preferred Method to Receive Refund

Signature