Fees for Service Refund Request

Your refund request will be processed within 6-8 weeks. For ACH refunds, refund checks will be mailed to the address you provide below.

Instructions: Required Fields are marked with an asterisk (*).

NOTE: Please avoid navigating the site using your browser's "Back" button. This may lead to the transmission of incomplete data and pages loading incorrectly. Please use the links provided whenever possible.
All fields in red indicate that invalid data has been entered in it.

*Identify method of original payment
ACH Credit Card

*Memo (reason requesting refund)


*Application Name:
*Date of Original Payment:
*Agency Tracking ID:
*Pay.Gov Tracking ID:
*Contact Name:
*Payee Name:
*Name on Credit Card:
Check Number:
*Original Transaction Date:
*Fee Amount Paid (US Dollars):
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip:
*Deposit Ticket Number:
*E-mail address:
*Phone Number (including area code):