Refund Request Form for Online Purchases

Fill this form out to request a refund for a purchased made on connect.recserv.uiowa.edu.

Customer Name (Last, First) *

Date of Original Transaction *

Month

Day

Year

Amount of Original Transaction *

Description of Item to Be Refunded *

Payment Transaction Order Number - Found on Emailed Receipt *

Credit Card Type Used for Transaction *

Visa

Mastercard

Discover

Invoice Number *

Last 4 Digits of Credit Card Used *

Customer Phone Number *

Customer Email *

Customer’s Address, City, State, and Zipcode *

Customer's Child’s Name

What program/class do you want a refund for? *

Full or Partial Refund? *

Full

Partial

Reason for Refund *

Submitted By *