Retail Payment Deferral Request Form
Submit your request to temporarily defer a retail payment. Please provide accurate details to help us review your application efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Retailer or Store Name
*
Last 4 Digits of Payment Card
*
Purchase Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Purchase Description (Item/Order/Invoice Reference)
*
Requested Deferral Period (number of months)
*
Please Select
1 month
2 months
3 months
Other (please specify below)
Briefly describe your reason for requesting a deferral (hardship context)
*
Preferred Contact Method
*
Email
Phone
Submit Request
Should be Empty: