Refund Request Form Name * First Name Last Name Email * Date of Issue MM DD YYYY Approximate Time of Issue Hour Minute Second AM PM Equipment Type: Washer, Dryer, Other Equipment Number (Listed on Front of Machine) Description of Problem (Include Error Code if applicable) Amount of Refund Requested $ Phone number (in case we have questions) (###) ### #### Laundry Card # (10 digit # on top right on back of card) Additional information Thank you! All refund requests will be reviewed for management approval as soon as possible All refund requests will be reviewed by management for approval as soon as possible