Finance Trademark Rebate Form

FINANCE TRADEMARK REBATE FORM

Applicant Information

Rebate Program Details

Program Name:    Program ID or Code:

Claim Submission Date:    Claim Reference Number (if previously assigned):

Trademark Information

Trademark / Service Mark Name:

Application Number:    Registration / Serial Number:

Jurisdiction (Country/Office):    Filing Date:    Registration Date (if applicable):

Eligible Expense Itemization

Provide detailed, itemized documentation for each cost claimed. Attach receipts, invoices, and proof of payment.

Attachments & Documentation

Please indicate attached documents included with this claim (check all that apply). All attachments must be legible and show amounts paid.

Registration certificate copy

Official filing fee receipts

Attorney invoices / proof of legal fees

Proof of payment (bank statement, remittance)

Power of attorney (if representative submits)

Payment & Remittance Instructions

Select preferred payment method. Payment will be issued in the name shown on this form and may require additional verification.

ACH / Direct Deposit

Check by mail

Wire transfer

Declarations, Certifications & Terms

By submitting this rebate claim, the Applicant certifies that all information and supporting documentation provided are true, complete, and accurate to the best of the Applicant's knowledge. Applicant acknowledges that funds will be disbursed only for eligible fees actually paid and may be subject to verification and audit. Applicant agrees to repay any amounts erroneously paid, including interest and administrative costs, if a subsequent review determines ineligibility or fraud.

Applicant authorizes the Program Administrator to request verification of payments from vendors, law firms, or financial institutions as necessary to validate this claim. Applicant acknowledges that processing times may vary and that incomplete submissions may be returned or delayed. Submission deadlines set by the program are strict; late claims may be denied.

Applicant further certifies under penalty of perjury that the amounts claimed were paid by the Applicant and not reimbursed by any third party. Applicant agrees to retain all original supporting documents for a period of at least three years from the date of payment and to provide them upon request.

I declare that I am authorized to make this claim on behalf of the Applicant entity and that this declaration is made under penalty of perjury.

I certify and attest to the declarations above and authorize verification as described.

Audit Consent & Release

Applicant consents to audits or reviews of the claim and authorizes disclosure of claim-related records to the Program Administrator or its authorized agents. Applicant releases the Program Administrator from liability for any claim determinations made in good faith based on the documentation provided and verified.

Applicant acknowledges that any rebate paid in error or obtained through misrepresentation is subject to recovery, including offsets against future payments, lien, or other lawful collection remedies.

Signature

Sign Now