Coin Refund Request
To expedite processing of your request, please submit only one request for all your refunds. Submitting multiple requests will not be allowed.
Fields with a star (*) are required.
Please enter information about the money you lost
Request Refund Amount*
  Please enter all machines that you lost your money from and explain thoroughly why you request for refund and justify your refund amount
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 (Line 1)* Apartment #: 
(Line 2): 
City*
State* Zip Code*
  You are required to verify your request. So please make sure that your email address is entered correctly.
Email Address*