Receipt for Refund

A Refund has been credited to your bank card for a previously submitted charge as follows: Type of Card: VISA, MasterCard or.Discover
Date of Charge ___________ _____________________________
Card Holder Name
Amount of Charge  $_____________
Total Credit Refund $_____________ _____________________________
Authorized User, if different
Refunded by:
Name ___________________________ _____________________________
Card Number
Address _________________________
________________________________ ______________
Expiration Date
Phone ___________________ ________________________
Date Refund was Submitted

    This credit refund will appear on your monthly card statement as from,or some abbreviation of it, and not the name of your provider.