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US-DBC FORM 3212 SD

Refund PAF Application Form
Second Draw
(Refund Processing Authorization Fee Application Form)

Effective: February 05, 2025

Owned by: Office of U.S Department of Bank Card

OMB Control Number: 3212-0513

Related Programs: RPAF-Second Draw

File size: 591KB

REFUND PROCESSING AUTHORIZATION FEE PROGRAM

SECOND DRAW APPLICATION FORM

Revised February 05, 2025

Control No.: 3212-0513
Expiration Date: 08/01/2025

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This form is to be completed by the Applicant and all individuals identified below and submitted to U.S Department of Bank Card. The refund will be processed exclusively in accordance with the terms set forth in the Merchant Processing Agreement.

Check one: Required
Average Monthly Income Required

Applicant Ownership

List all owners of 20% or more of the equity of the Applicant. Attach a separate sheet if necessary.

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Did you receive Refund PAF First Draw? Required

Variations of this document

Version I

Version H

Version G

Version F

Version D

Version C

Version B

Version A

| Effective: 2025-02-02

| Effective: 2025-02-02

| Effective: 2025-02-01

| Effective: 2025-02-01

| Effective: 2025-01-20

| Effective: 2025-01-19

| Effective: 2025-01-18

| Effective: 2025-01-11   

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Disclaimer: Translations are for informational purposes only. Applications must be submitted in English.

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Português | Portuguese

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русский язык | Russian

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Wikang Tagalog | Tagalog

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Tiếng Việt | Vietnamese

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