Coin Refund Request

If you lost your money on multiple machines, please enter one of your machines in the Machine ID field, enter the total amount of refund on all your machines in the Refund Amount field, and enter your additional machines in the Refund Reason field.

Fields with a star (*) are required.
Please enter information about the money you lost
Request Refund Amount*
  Please explain thoroughly the reason for your refund request
Refund Reason*
Please enter information about location of the machine problem
Property Name*
  Examples: White Dove Apartments or 1234 Main Street
Property Address 
(#*, Name*, Type): 
  
  Example: 1234MainStreet
City*
State* Zip Code*
Please enter your mailing address information
First Name*
Last Name*
Phone Number*
Mailing Address* Apartment #: 
 
City*
State* Zip Code*
If you would like a confirmation of this request, please enter your contact information
Notify By:    
Email Address: