Form template · Refund Request Form Template
Updated · plan facts checked against /pricing
A refund request form is how a customer asks for their money back: the order number, how much, how they paid and why. This free HTML template has 15 fields, including a reason list, whether there is an item to send back, and an optional receipt or screenshot. Every request reaches your inbox and dashboard, time-stamped.
This template is one of our free HTML form templates. See more form templates by industry.
Overview
Online stores, course creators, service businesses, venues and subscription products all get refund requests, and most arrive missing the order number or the amount. This template is a plain HTML form that posts to one splitforms endpoint (https://splitforms.com/api/submit) with a hidden access_key, so it can sit on a help page, an order-status page or a static site with no backend. Each request is emailed to you on every plan with a Lead number, and saved in the dashboard with the time it arrived, which is your record of when the customer asked.
No server, API route, or SDK — your Refund Request Form posts straight to one endpoint.
Every submission is emailed to you and saved to a searchable dashboard — spam filtered before it reaches you.
It's plain HTML you own — paste the Refund Request Form snippet, swap in your access key, and ship.
Copy and ship
Plain HTML that posts to the /api/submit endpoint. Replace YOUR_ACCESS_KEY with the key from your dashboard; that's the only edit.
<form action="https://splitforms.com/api/submit" method="POST" enctype="multipart/form-data">
<input type="hidden" name="access_key" value="YOUR_ACCESS_KEY">
<input type="hidden" name="subject" value="New refund request">
<input type="hidden" name="form_loaded_at" id="form_loaded_at">
<fieldset>
<legend>Your order</legend>
<label>Full name <input type="text" name="name" autocomplete="name" required></label>
<label>Email used for the order <input type="email" name="email" autocomplete="email" required></label>
<label>Order or invoice number <input type="text" name="order_number" required></label>
<label>Purchase date <input type="date" name="purchase_date" required></label>
<label>How did you pay?
<select name="paid_with" required>
<option value="">Choose one</option>
<option>Credit or debit card</option>
<option>PayPal</option>
<option>Bank transfer</option>
<option>Cash</option>
<option>Other</option>
</select>
</label>
</fieldset>
<fieldset>
<legend>What should be refunded?</legend>
<label><input type="radio" name="refund_scope" value="Whole order" required> The whole order</label>
<label><input type="radio" name="refund_scope" value="Part of the order"> Part of the order</label>
<label>Which items (if part of the order) <input type="text" name="items_to_refund"></label>
<label>Amount you're asking for, if you know it
<input type="number" name="amount_requested" min="0" step="0.01" inputmode="decimal">
</label>
</fieldset>
<fieldset>
<legend>Why are you asking for a refund?</legend>
<label>Reason
<select name="reason" required>
<option value="">Choose one</option>
<option>Charged twice or charged the wrong amount</option>
<option>Order never arrived</option>
<option>Arrived damaged or faulty</option>
<option>Not as described</option>
<option>Service not provided as agreed</option>
<option>Cancelled before delivery or start date</option>
<option>Changed my mind</option>
<option>Other</option>
</select>
</label>
<label>What happened? <textarea name="details" rows="4" required></textarea></label>
</fieldset>
<fieldset>
<legend>Is there an item to send back?</legend>
<label><input type="radio" name="item_status" value="No item" required> No item (a service, subscription or billing error)</label>
<label><input type="radio" name="item_status" value="Still have it"> I still have the item</label>
<label><input type="radio" name="item_status" value="Already returned"> I've already sent it back</label>
<label>Return or RMA number, if you have one <input type="text" name="return_reference"></label>
</fieldset>
<fieldset>
<legend>How would you like it resolved?</legend>
<label><input type="radio" name="resolution" value="Refund to original payment" required> Refund to my original payment method</label>
<label><input type="radio" name="resolution" value="Store credit"> Store credit</label>
</fieldset>
<!-- Files are stored on paid plans; the Free plan drops uploaded files -->
<label>Receipt, screenshot or photo (optional)
<input type="file" name="evidence" accept="image/*,.pdf">
</label>
<label><input type="checkbox" name="policy_ack" value="yes" required>
I have read the <a href="/refund-policy">refund policy</a>.</label>
<!-- honeypot: leave empty -->
<input type="checkbox" name="botcheck" style="display:none" tabindex="-1" autocomplete="off">
<button type="submit">Send refund request</button>
</form>
<script>
document.getElementById('form_loaded_at').value = Date.now();
</script>Field by field
email (used for the order)order_number (required)paid_with (select)refund_scope + items_to_refund + amount_requestedreason (select, required)item_status (radio, required)resolution (radio)evidence (file, optional)policy_ack (checkbox, required)How to add it
To add a Refund Request Form to your site you need three things: a free splitforms access key, the HTML snippet above, and your key pasted into it. No backend, database, or CAPTCHA library — the form posts to one URL and every submission lands in your inbox and dashboard.
Point the policy link at your refund policy, edit the reason list for your business, and remove store credit if you don't offer it. Swap in your access key and publish the form on your help or order-status page.
Each request is emailed to you with a Lead number. Match the order number and amount against your records; for items the customer still has, send return instructions before refunding.
Refund in your payment provider (Stripe, PayPal, your card terminal) or as store credit, then reply to the customer with the amount and the Lead number as the reference.
What's included
Refund requests that arrive as a one-line email ('I want my money back') take three replies before you can decide anything: which order, how much, paid how, and is there an item coming back. This form asks all of that once. The item-status question is the one most refund forms skip, and it decides your next step: a duplicate charge or an undelivered service can be refunded straight away, while a physical product usually needs a return first, which is a separate return authorization (RMA) step. Asking for the reason from a fixed list also gives you something to count later, so you can see whether refunds come from shipping damage, unclear descriptions or billing mistakes. Money back, not a product return: the item-status question tells you which path a request takes.
Where submissions go
Reply-to is wired to the visitor's email, so one tap on Reply answers them directly — while the built-in honeypot and automatic spam scoring filter out bots before they reach you. Every submission is emailed to your inbox and can forward to a webhook or Slack the moment a visitor hits send.
How SplitForms works
splitforms receives the submission, filters spam, saves it to your dashboard and emails you — then, on paid plans, sends it on to your webhooks and integrations. No backend infrastructure to build.
Point your form to your unique SplitForms endpoint. That's it.
We instantly capture and organize every submission in your inbox.
Send data to email, spreadsheets, CRMs, webhooks, and 7,000+ apps.
No credit card required. Set up in under 60 seconds.
Connect & automate
On paid plans, submissions can also go to Slack, Discord, Google Sheets, Notion, Airtable, Zapier or any signed webhook — and splitforms works on the platforms you build on, from WordPress and Shopify to Next.js. With Stripe connected, your forms can take payments too.
NewTake payments on your formsDeposits, bookings, order forms — submitters check out through Stripe and the money goes straight to your Stripe account. Included on every paid plan.See payment forms →Need time slots? Online booking →Questions
As fast as you reasonably can, even if the decision takes longer. A customer who hears nothing may ask their card issuer for a chargeback instead. On paid plans, the auto-reply can confirm receipt immediately and state the response time you commit to.
Yes, on paid plans. Notification routing can send a request to a different recipient based on the reason chosen, so 'Charged twice' goes to whoever handles billing and 'Arrived damaged' goes to whoever handles returns. On the Free plan every request goes to your form's notification address.
Search the dashboard by email address or order number; it matches the values people submitted. On paid plans, export the CSV to count requests per customer or per reason over a month.
It can't guarantee that. What it does is give customers a clear way to ask you first, and give you a time-stamped record of what they asked for and when you replied. Answer quickly and keep your refund policy easy to find.
The customer's name and the email used for the order, the order or invoice number, the purchase date, how they paid, whether it is a full or partial refund, the reason, what happened, whether there is an item to send back, and their preferred resolution. A receipt or screenshot upload helps for billing errors and damage.
A refund request form asks for money back and covers cases with no product at all, such as a duplicate charge or a cancelled service. An RMA (return merchandise authorization) form asks permission to send a product back for a refund, exchange or repair. If a refund depends on a returned item, approve the return first, then refund when it arrives.
No. splitforms collects and stores the request; you issue the refund in whatever took the payment. If the customer paid through a splitforms Stripe payment form, the charge is in your own Stripe account, and refunds are made from your Stripe dashboard.
Simple pricing
Free gives you 500 submissions for $0 — no card, no time limit. Pro is $5/month for 5,000 submissions a month, and Annual is $49/year for 15,000 a month with every Pro feature.
For side projects and indie devs.
Every paid feature, for agencies and growing products.
Every Pro feature with triple the volume — $0.27 per 1,000 at full use.
No credit card required on Free • Cancel anytime • Full pricing and FAQ
