Fees and Charges Dispute Form

If you believe you were billed for fees or charges in error, use this form to request a refund. Please send supporting documents for your claim.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP

Email(Required)

Phone(Required)

Disputed Amount(Required)

Comments(Required)

Please explain why you believe that you are not responsible for this charge. Provide as much detail as possible.

Supporting Documentation

Drop files here or

Accepted file types: pdf, jpg, png, doc, Max. file size: 10 MB, Max. files: 10.

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Name

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