Prescribed Products Refund Form

Office of Vermont Attorney General
109 State Street
Montpelier, VT 05609-1001

Refund Requestor

Manufacturer

Make Payable to

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Name

Title

Telephone

Confirm email

Fed ID #

Information on Original Check

Manufacturer

Check Number: (Use "CC" if payment was by Credit Card)

Check Amount $

Reporting Period

Certification

I hereby certify that the above manufacturer had no prescribed products disclosures to report for the period state above.

Compliance Officer Name

Compliance Officer Title

Compliance Email Address

Confirm email

Date

Refunds of registration fees may not be reviewed for approval and processing until 60 days after the reporting deadline

Please note: Anything you submit to the Attorney General’s Office may be subject to disclosure under Vermont’s Public Records Act.

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.