Bill Correction and Refund Escalation Request

Backend Form Name

GroupName

Subject

FileName

Is New Incident Attachment

NoYes

T-Mobile Employee Information

T-Mobile Employee NTID/ADID *

T-Mobile Employee Email Address *

Re-enter T-Mobile Employee Email Address *

Email Addresses does not Match. Please Re-enter

Support / Customer Information

Is this a current T-Mobile Customer? *

BAN/FAN *

This field must contain 9 digit(s).

MSISDN / Mobile Number

This field must contain 10 digit(s).

Is this Equipment or Bill Payment? *

Payment ID *

Order/Transaction Number *

First Name *

Last Name *

Street address Line 1 *

Street address Line 2

City *

State *

Zip *

Is this a Sprint Account: *

Account Type *

Is this a metro customer? *

Transaction Date:

Payment Amount $ *

Was a refund already issued? *

Is this a partial refund request? *

Cash Correction Amount Requested *

Did you pay cash? *

How was the Payment Made? *

CheckNumber

Method of payment? *

First six digits of the card or bank account number used for the payment:

This field must contain 6 digit(s).

Last four digits of the card or bank account number used for the payment: *

This field must contain 4 digit(s).

Please Specify *

Store Number

Please provide details of request

Supporting Documents(s)

Attach a document from the list below. For your security, please ensure ONLY the last four digits of the card or bank account number is visible.

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