E-commerce Refund Reconciliation Report Form
Use this form to report, review, and reconcile e-commerce refund cases against the original order and payment record.
Refund Case Identification
Order Number
*
Refund Request Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Refund Status / Case Stage
*
Please Select
Pending Review
Approved
Processed
Rejected
Partially Refunded
Customer and Order Details
Customer Name
*
First Name
Middle Name
Last Name
Customer Email
*
example@example.com
Customer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Order Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Order Channel / Storefront
*
Please Select
Website
Mobile App
Marketplace
In-Store
Social Commerce
Other
Order Reference
Refund Request Details
Refund Type
*
Full Refund
Partial Refund
Item Return Refund
Shipping Fee Refund
Other
Refund Amount Requested
*
Currency
*
Please Select
USD
EUR
GBP
CAD
AUD
JPY
Other
Original Payment Method
*
Please Select
Card
Wallet
PayPal
Gift Card
Bank Transfer
Other
Was the Item Returned?
*
Yes
No
Not Applicable
Item and Product Information
Refunded Item(s)
*
Primary Item Name
Primary Item SKU
Brief Item Condition / Return Reason Note
Reconciliation Review and Resolution
Reconciliation Outcome
*
Matched
Mismatch Found
Under Review
Resolved
Discrepancy Amount
Discrepancy Notes
Responsible Team / Member
*
Resolution Notes
Internal Follow-up Action / Next Step
Submit Report
Should be Empty: