Online Dating App Payment Issue Report Form
Please complete this form to report a payment issue with your online dating app account. We will review your submission and contact you for further information if needed.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Payment Method Used
*
Please Select
Credit/Debit Card
PayPal
Apple Pay
Google Pay
Other
Date of Transaction
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Transaction Amount (USD)
*
Transaction Reference or Order ID (if available)
Last 4 Digits of Payment Card (if card was used)
Describe the Payment Issue
*
Upload Screenshot or Supporting Document (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Report
Should be Empty: