Immigration Health Surcharge Refund Request Form

Immigration Health Surcharge Refund Request Form
Use this form to request a refund of the Immigration Health Surcharge and provide the details needed to review and process your request.
Applicant Details
Full Legal Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Country of Residence
Current Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Immigration and Refund Information
Immigration or visa application type
Current immigration status or visa type
Reason for requesting the refund
Date the surcharge was paid
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Application or reference number
Supporting Details and Documents
Relevant date(s) for this refund request
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous refund attempts or related case history
Upload supporting documents
Cancelof
Refund Preferences and Declaration
Preferred refund destination
Other
Additional instructions or notes
Declaration
Should be Empty: