Pre-payment Dispute Form

This form below is to be used to dispute pre-payment fees associated with an installation appointment.

Please note that calling, sending emails, or repeatedly resending the same dispute will delay the initial and entire request.

"* (required)" indicates required fields

Please select the pre-payment you are disputing:* (required)

Enrollment

$40 Partial Lease Payment

Terms & Conditions

Before proceeding, you must read and agree to the Terms and Conditions:

Terms and Conditions* (required)

The pre-payment dispute should only be completed by customers who have not installed a device, do not have a pending installation appointment, and have paid either an enrollment fee or $40 towards the first month's lease.

If it is determined that a refund is to be issued, the refund will be issued in the form of a check delivered to the mailing address entered on this form.

Simple Interlock holds the right to cancel a dispute if a chargeback was issued to the original form of payment.

I have read and agree to the Terms and Conditions

State* (required)

Account Holder Details

Full Legal Name* (required)

First Last

Date of Birth* (required)

Email Address* (required)

Phone* (required)

Mailing Address for Refund (if issued)* (required)

Street Address Address Line 2 City State ZIP Code

Reason for Dispute* (required)

Please allow between five (5) to seven (7) business days for an official response.

Disputes are determined on a case-by-case basis and are not guaranteed for all clients submitting the form.

Name

This field is for validation purposes and should be left unchanged.