Prepaid Gift Card Settlement Refund Claim Form

Prepaid Gift Card Settlement Refund Claim Form
Submit your claim for a refund related to the prepaid gift card settlement. Please provide accurate information and required documentation.
Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Gift Card Issuer
Type of Gift Card
The Last 4 Digits of Your Gift Card
Original Card Value (USD)
Purchase Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location or Website Where Gift Card Was Purchased
Refund Amount Requested (USD)
Upload Proof of Purchase or Gift Card (e.g., receipt, card image)
Cancelof
Additional Comments (if any)
Signature
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