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MEN of MEANS

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This form must be completed by the Men of Means Sponsor only

Member Name:*

Sponsor Name:

Tribe Name:

Date of Last Charge:*

Month

Day

Year

Dispute Amount:*

Reason for Refund Request:*

What Measures Have You Taken to Ensure We Can Provide Service as Support to a Refund:*

What Can We Do to Prevent the Member from Leaving:*

Any Other Feedback:

Sponsor Name & Date:

Signature:*

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Date:*

Month

Day

Year

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