REFUND REQUEST FORM

Please enter your details on the form

*Required

1. Name of the Customer *

2. Email Address *

3. Aadhar Number *

4. Country Applying from *

5. Currency Required *

6. Application Reference Number *

7. Date of Transaction*

8. Transaction ID *

9. Amount to be Refunded *

10. Reason for Refund *

BANK & COURIER DETAILS

BANK ACCOUNT/ CARD HOLDER NAME-

BANK ACCOUNT NUMBER-
NAME OF BANK-
BANK BRANCH-
CHEQUE TO BE MADE IN NAME OF (ORIGINAL AMOUNT)-
ADDRESS-
CITY-
STATE-
PIN CODE-
LANDMARK-
RECEIVER NAME-
CONTACT NUMBER-

DECLARATION

I (Name) (Father’s Name)

(Address)
declare that all information provided above is true and correct. I also confirm to pay required fees 10
% with G.S.T for mandatory remittance tax, bank settlement charges for inward remittance and
currency conversion charges in case of denaying I shall be not liable to ask for refund.

Note: The funds will be returned to whatever payment method (credit card, bank account) that the
payer initially used to make the payment.

Name and Signature: Date: