Fuel Refund Request

FUEL REFUND REQUEST AND SETTLEMENT AGREEMENT

Parties and Request Identification

Requesting Party Name:

Responding Party Name:

Request Reference Number:    Request Date:

WHEREAS

WHEREAS, Requesting Party purchased fuel products and related services from Responding Party pursuant to invoices and delivery receipts identified in this request; and

WHEREAS, Requesting Party asserts that charges for one or more transactions were incorrect due to overbilling, incorrect taxes, duplicate billing, or product quality issues, and seeks a refund, credit, or adjustment for the amounts set forth below; and

WHEREAS, Responding Party is authorized to investigate and, if liability is established, to issue a refund or credit in accordance with the Payment Terms and Settlement provisions contained herein.

Transaction Details (Itemize each disputed transaction)

Provide supporting invoice or delivery receipt numbers and amounts for each disputed transaction. Attach copies as required to substantiate the claim.

Scope of Work / Basis for Refund

Payment Terms

Total Refund Amount Requested:

Issue credit to account    Issue company check    Wire transfer

Payment Schedule: Responding Party will remit any approved refund within days from issuance of written approval or settlement confirmation.

Late Fee / Interest: If Responding Party fails to remit an approved refund by the Payment Schedule, the outstanding amount shall accrue interest at the lesser of (a) % per month compounded monthly, or (b) the maximum rate permitted by applicable law.

Term and Termination

Effective Date:    Termination Date (if applicable):

Notice of Termination: Either party may terminate consideration of this request by delivering written notice to the other party with at least days' prior notice. Termination of consideration shall not affect rights to refunds or credits established prior to termination.

Confidentiality

All non-public information submitted in connection with this Fuel Refund Request, including transactional records and pricing data, shall be treated as confidential by the receiving party and shall not be disclosed except as required by law or to its professional advisors on a need-to-know basis, provided that such advisors are bound by confidentiality obligations no less protective than those set forth herein.

Representations, Warranties and Certification

The Requesting Party represents and warrants that it is authorized to submit this claim, that the information provided is true, complete and accurate to the best of its knowledge, and that it has not assigned or otherwise transferred any right to recover the disputed amounts to any third party. By submitting this request, the Requesting Party certifies that the claimed amounts have not been refunded previously by Responding Party.

I certify under penalty of perjury that the facts set forth in this Fuel Refund Request are true and correct and that I am authorized to submit this claim on behalf of the Requesting Party.

I certify that the information provided is accurate and that I have authority to request the refund on behalf of the Requesting Party.

Governing Law; Entire Agreement

This Fuel Refund Request and any resulting settlement shall be governed by the laws of the state indicated by the Responding Party's principal place of business, without regard to conflict of law principles. This document, together with any written settlement communications executed by both parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, understandings and agreements.

Remedies and Limitation

The parties' sole remedies for an approved refund shall be limited to the refund or credit of amounts determined to be owing. Neither party shall be liable for incidental, consequential, or punitive damages arising from the transactions described in this request, except as otherwise required by applicable law.

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