CBD Surcharge Reimbursement Request
Submit your request for reimbursement of surcharges related to CBD transactions. Please provide accurate details and supporting documentation.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Transaction Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Merchant or Store Name
*
Amount of Surcharge (USD)
*
Last 4 Digits of the Card Used
*
Reason for Reimbursement
*
Upload Proof of Surcharge (e.g., receipt, card statement)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Preferred Method of Reimbursement
*
Check
Electronic Payment (e.g., PayPal, Venmo)
Store Credit
Additional Comments (optional)
I confirm that the information provided is accurate and that I am requesting reimbursement for a legitimate surcharge related to a CBD transaction.
*
Submit Reimbursement Request
Submit Reimbursement Request
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