Global Express Bill Pay Research Request Form (Lost Receipt) - Maryland Bill Pay Tracer Department

GLOBAL EXPRESS BILL PAY RESEARCH REQUEST FORM (LOST RECEIPT)

Use this form if your service provider has not applied your payment and you have lost your bill pay receipt.

Instruction: Complete all required information before mailing this form. Incomplete forms will be returned.

1. A Three Dollar ($3.00) non-refundable processing fee payable to Global Express

provider. Please check the appropriate box below to indicate what action you would like us to take.

(money orders or certified checks only, no personal checks) must be included with each form.

Note: If you request that we resubmit your payment, a copy of your service provider’s invoice must accompany this form.

2. Submit a separate form for each payment that you want researched.

4. Once you complete this form, it must be notarized by a notary public.

3. In most circumstances, you have the option of receiving a refund check or resubmitting the payment to your service

5. Keep a photocopy of this form for your records.

MAIL TO:

Bill Pay Tracer Department

ALLOW UP TO 30 DAYS FROM THE RECEIPT OF THIS REQUEST FOR PROCESSING

P.O. Box 8608 Silver Spring, MD 20907

For questions call: 301-495-3560, Hours: 8:30 a.m.-5:00 p.m. EST

COMPLETE ALL INFORMATION

First Name

Service Provider Name

Last Name

Current Mailing Address

Service Provider Account Number

Payment Amount

Payment Date

City

State

Zip Code

$

/

/

Day Time Phone Number

Home Phone Number

Payment Location Name (Optional)

IF THE INFORMATION YOU PROVIDE IS ACCURATE AND COMPLETE, YOU HAVE TWO OPTIONS (PLEASE CHECK ONE):

PLEASE SEND ME A REFUND CHECK FOR THE PAYMENT AMOUNT:

PLEASE RESUBMIT MY PAYMENT AMOUNT TO MY SERVICE PROVIDER:

Under penalties of perjury, the undersigned represents, warrants, certifies and/or agrees:

1.

I provided a Global Express trustee with the payment amount indicated above and authorized that such payment amount be transferred to the service provider indicated above. I am unable to locate the receipt that describes the transaction. If I ever find the receipt, I will

promptly deliver it to Global Express at the above address.

2.

I have the legal right to receive a refund of the payment amount or the authority to direct that Global Express resubmit the payment amount to my service provider.

3.

I will indemnify and hold Global Express harmless from and against any and all obligations, liabilities or damages to Global Express that arise, directly or indirectly, from any inaccurate statement made by me on this from.

4.

I will repay Global Express any amounts refunded to me or paid to my service provider in the event that, notwithstanding my request on this form, the payment amount indicated above is paid to one of my service providers for my benefit.

5.

I release and hold Global Express harmless and Global Express shall have no liability for any obligations, liabilities or damages to me (including, without limitation, damages as a result of late fees, service interruptions and cancellations) as a result of my original

payment not being processed. I also agree that Global Express shall not be liable to me for any consequential, special, indirect, incidental or punitive damages (even if Global Express has been notified of the possibility or likelihood of such damages occurring).

6.

If any statement on this form is incorrect or incomplete, if this form is not signed and notarized, or if the $3.00 payment does not accompany this form, Global Express has no obligation to process this form.

SIGN AND DATE BELOW IN THE PRESENCE OF A NOTARY PUBLIC

Signature: ______________________________________________________________ Print Name: ____________________________________________________________

Date: __________________________________________________________________ State of ________________________________________________________________

I HEREBY CERTIFY, on this ____ day of __________________, 200___, before me, a Notary Public of said State, personally appeared_________________________________________, known to me (or satisfactorily proven) to be the person whose name is

subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained as aforesaid.

My Commission Expires:________________________________________

____________________________________________________________________

Notary Public

BP02B 02/05