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Intake Form - Payment Processors

Request for Account and Business Information. Please complete all sections as accurately as possible.

1. Account Details

Payment Processor or Bank

Name of the payment processor or financial institution managing the account.

Date of Account Opening

Account Holder - Full Name

Account Holder - Company Name

Company Registered Address

Company Registration Number

Passport / ID Number

Account ID

Website Used Through the Payment Processor

Associated Bank Account Liquidity

2. Suspension Information

Date of Account Suspension

Reason for Suspension

Suspension Emails

Please attach copies of any suspension-related communications.

3. Financial Information

Amount of Money Blocked

Monthly Revenue Processed - Last 6 Months

Last Payout Date

Website Linked to Account

Average Price per Item / Transaction

4. Dispute and Chargeback Information

Total Number of Disputes

Disputes Won

Disputes Lost

Total Value of Disputes

Total Number of Refunds

Total Value of Refunds

Dispute Rate

5. Fulfillment and Service Delivery

Service Delivery (for digital services) - Have you provided the service?

Service Delivery (for digital services) - Have you provided the service?
A
B

Number of services provided / not provided

Order Fulfillment (for physical items) - Have you fulfilled the orders?

Order Fulfillment (for physical items) - Have you fulfilled the orders?
A
B

Number of orders fulfilled / not fulfilled

6. Account Activity

Summary of Account Activities

7. Compliance and Supporting Documents

Compliance Documents

Please attach: business license/registration, tax identification, supplier agreements, logistics/shipping agreements.

Proof of Fulfillment for Disputed Transactions

Attach tracking information or proof of delivery for disputed transactions.

8. Risk Mitigation and Fraud Prevention

Fraud Prevention Measures

Refund and Return Policies

9. History of Deactivation or Account Restraints

Is this the first time the account has been subject to deactivation or account restraint by any payment processor?

Is this the first time the account has been subject to deactivation or account restraint by any payment processor?
A
B

Prior deactivations - Payment Processor names and associated emails

10. Customer and Reputation Management

Customer Satisfaction Metrics

Communication Logs

Provide logs or screenshots of customer communications related to disputes or complaints.