Can this form be submitted electronically?

Yes. Electronic submission is acceptable provided the platform preserves an audit trail and the signature meets ESIGN Act criteria for intent, consent, attribution, and retention (15 U.S.C. ch.96).

Who can approve a credit request?

An authorized finance manager or designated procurement officer with documented approval authority in your internal policy should sign the form to validate the request.

What supporting documents are required?

Include the invoice or transaction ID, a description of the issue, screenshots or logs, and any prior correspondence that substantiates the claim to expedite verification.

How long does processing typically take?

Processing time varies by account tier and complexity; simple requests often complete within 5–10 business days, while disputed or high-value claims may take longer.

How do I correct a submitted form?

Contact the billing team with the tracking ID, supply corrected fields and attachments, and note the changes; maintain prior submission records for audit continuity.

Can a credit be reversed after posting?

Yes. If an error is discovered post-posting, finance may reverse or reallocate the credit following internal controls and documented approver authorization.

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Qualtrics Credits Request Form

Qualtrics Credits Request Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

QUALTRICS CREDITS REQUEST FORM

This Credits Request Form (the Agreement) documents the allocation, payment and use of Qualtrics platform credits between the requesting organization and the provider. Completion of this form and subsequent signatures by authorized representatives create a binding agreement for the issuance and use of the credits described below, subject to the terms set forth herein.

Parties and Administrative Data

Requesting Organization Requestor Name and Title

Email:

Phone:

Qualtrics Account ID Department / Cost Center

WHEREAS

WHEREAS, Requesting Organization desires an allocation of Qualtrics service credits for use in survey distribution, data collection, and related services in support of the Project identified in this form; and

WHEREAS, Provider agrees to allocate the requested credits to the designated Qualtrics account on the terms and conditions set forth in this Agreement, subject to availability and internal approval processes; and

WHEREAS, the parties intend that issuance and use of credits will be governed by the Payment Terms, Confidentiality, and other provisions in this Agreement.

Project Details and Scope of Work

Project Name Project Manager Scope of Work (describe how credits will be used)

Credits Requested

Number of Credits:

Credit Type(s): Survey Responses SMS Other

Justification for Credits

Payment Terms

Provider will invoice Requesting Organization for the credits allocated under this Agreement in accordance with the terms below. All fees are payable in U.S. dollars unless otherwise agreed in writing.

Total Fee for Credits Payment Schedule

Late payments shall accrue interest at the lesser of 1.5% per month or the maximum rate permitted by law, and Requesting Organization shall be responsible for reasonable collection costs.

Late Fee Rate (annualized)

Term and Termination

The term of this Agreement begins on and ends on unless earlier terminated in accordance with this section.

Either party may terminate this Agreement for convenience upon written notice delivered at least days prior to the effective termination date. Provider may suspend credit issuance in the event of non-payment or material breach by Requesting Organization after ten (10) days' written notice and an opportunity to cure.

Confidentiality

Each party agrees that Confidential Information disclosed in connection with this Agreement will be held in strict confidence and used only to perform obligations under this Agreement. Confidential Information does not include information that is or becomes generally known to the public other than by breach of this Agreement, or that is rightfully received from a third party without restriction. The receiving party shall use at least the same degree of care to protect Confidential Information as it uses to protect its own confidential information, but in no event less than reasonable care.

Representations; Use Restrictions

Requesting Organization represents that credits will be used solely for legitimate research, evaluation, or business needs consistent with the Qualtrics platform terms and all applicable laws. Redistribution, resale, or transfer of credits to unrelated third parties is prohibited unless expressly authorized in writing by Provider.

Governing Law

This Agreement will be governed by and construed in accordance with the laws of the state of without regard to its choice of law principles. Exclusive venue for any dispute arising under this Agreement shall be the state or federal courts located within that state.

Entire Agreement

This Agreement, including any attachments or schedules executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous understandings and agreements, whether written or oral. Any amendment or modification must be in writing and signed by authorized representatives of both parties.

Administrative Approvals

Budget approval: Approved Declined

Approving Manager / Finance Contact

Approval Date:

Certification and Acknowledgement

By signing below, Requesting Organization certifies that the information provided in this form is true and accurate, that it has authority to request the credits on behalf of the organization, and that it accepts the terms and conditions of this Agreement. Provider confirms issuance of credits subject to payment and applicable policies.

Requesting Organization - Printed Name:

By (Signature):

Date:

Provider - Printed Name:

By (Signature):

Date:

What the Qualtrics Credits Request Form Is

The Qualtrics Credits Request Form is a standardized document used to request account credits, adjustments, or promotional allocations within a Qualtrics account. Typical uses include billing dispute resolution, credit issuance for service interruptions, application of promotional or partner credits, and internal reallocations for research or survey projects. The form collects account identifiers, transaction or invoice references, the requested credit amount, justification and supporting documentation, and an authorized approver's details. Completed forms route to Qualtrics billing or finance teams and may be submitted electronically; processing timelines and evidence requirements vary by account type and contractual terms.

Why Use a Formal Credits Request Form

Using a standardized form ensures consistent information collection, reduces back-and-forth, and creates an auditable record for finance teams and auditors.

Who Completes and Approves This Form

Typical filers and approvers are organizationally defined to control credit issuance and prevent misuse.

Project managers requesting research or survey credits who supply project codes and justification for finance review.
Billing or procurement staff submitting adjustments tied to invoices, subscriptions, or partner discounts.
Approvers such as finance leads or procurement officers authorized to sign off on credit amounts and policy compliance.

Clear role separation helps maintain internal controls and provides traceability for audits and external reviews.

Step-by-Step: Submitting a Credits Request

Follow these sequential steps to prepare and submit a complete request for timely processing.

01

Gather Documents: Collect invoices, transaction IDs, and supporting screenshots.
02

Complete Form: Enter all required fields and double-check amounts.
03

Attach Evidence: Upload supporting files in PDF or image format.
04

Obtain Approval: Ensure an authorized approver signs before submission.

Where the Form Goes and What Happens Next

Routing steps show how the request moves from submission to credit application and notification.

Submit: Sender uploads form and attachments to the designated portal or email recipient.
Finance Review: Billing team verifies account, invoice, and supporting evidence.
Approval: Authorized approver confirms eligibility and signs off.
Credit Application: Finance posts credit to the account and notifies requester.

How to Configure an Online Request Workflow

Design the online workflow to collect fields, enforce approver steps, and preserve audit logs.

Field	Configuration
Submission Destination	Qualtrics billing queue or designated finance email
Authentication	Email verification or SSO enforced for internal users
Attachments Allowed	PDF, JPG, PNG; limit file size per attachment
Auto Acknowledgement	Generate receipt email with tracking ID

Platform and File Requirements for eSubmission

Ensure the submission platform accepts standard file types and preserves an audit trail for compliance.

File Formats: PDF, DOCX, PNG accepted
Integrations: Supports Salesforce, Microsoft 365, Google Workspace
Security: TLS in transit and AES-256 at rest

Use a platform that records timestamps, signer identity, and maintains tamper-evident storage for audit purposes.

Sample eSignature Pricing Options for Submitting the Form

Common eSignature providers differ by price model, bulk-send capability, and compliance features. signNow appears first for comparison.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Core Components of a Professional Credits Request

A complete form combines identifying data, transaction details, evidence, approval, processing instructions, and an audit trail to support downstream accounting.

Account Details

Full account name, account ID, billing contact, and billing address to ensure requests route correctly and apply to the intended subscription.

Transaction Reference

Invoice number, date, and relevant transaction identifiers to tie the credit to a specific charge or billing period.

Requested Amount

Clear numeric value with currency and calculation notes for prorations, refunds, or partial credits to avoid ambiguity.

Supporting Evidence

Attach screenshots, error logs, or correspondence that substantiate the request and shorten verification time.

Approvals

Name, title, and electronic signature of an authorized approver to satisfy internal control and audit requirements.

Processing Notes

Preferred settlement method, GL coding, and any urgency flags so finance can post credits correctly and promptly.

Practical Tips for Accurate and Fast Processing

Small preparation steps reduce review time and the chance of rejection.

Use Exact Identifiers

Provide the exact account ID and invoice reference rather than a descriptive project name to avoid misrouting.

Attach Clear Evidence

Include date-stamped screenshots or exportable logs showing the error or duplication you are claiming.

Confirm Approver Authority

Verify the listed approver has documented authorization to approve credits per internal policy.

Preserve Audit Trail

Submit via platforms that keep timestamps and signer identity to satisfy ESIGN and internal audit needs.

Consequences of Incorrect or Fraudulent Requests

Delayed Processing: Missing or incorrect IDs cause processing delays and additional verification steps

Credit Rejection: Insufficient evidence may result in request denial and account balance remaining unchanged

Internal Discipline: Fraudulent submissions can trigger internal investigation and disciplinary action

Tax Withholding: Incorrect payee data could trigger backup withholding obligations (24%)

Data Privacy: Improper PHI disclosure risks HIPAA violations and fines (45 CFR §164.530(j))

Legal Invalidity: Unsigned or unauthorized approvals may be unenforceable under ESIGN (15 U.S.C. ch.96)

Common Preparation Errors to Avoid

Using nonstandard account names instead of the official Account ID
Failing to attach supporting invoices or screenshots showing the issue
Submitting without an authorized approver signature or documented authority
Uploading unreadable or password-protected attachments that reviewers cannot open

Real-World Examples of Credits Requests

Illustrative cases show how common problems are documented and resolved using a formal request form.

Optica Ventures — COO

A research team identified duplicate survey charges and submitted a single form with invoice references and logs.

The billing team validated timestamps.
The credit was issued and applied to the next billing cycle after finance confirmed the duplicate charge and obtained the required approver signature.

Martin Properties — Founder

A property survey rollout required reallocation of previously purchased credits; the requester attached purchase receipts and project codes.

Finance reviewed allocation terms.
Credits were reallocated to the correct project after approval, and an audit entry preserved the decision for future reconciliation.

Frequently Asked Questions about the Credits Request Form

Answers to frequently asked questions address common legal, procedural, and technical issues when submitting credits requests.

Need help? Contact support

Can this form be submitted electronically?
Yes. Electronic submission is acceptable provided the platform preserves an audit trail and the signature meets ESIGN Act criteria for intent, consent, attribution, and retention (15 U.S.C. ch.96).
Who can approve a credit request?
An authorized finance manager or designated procurement officer with documented approval authority in your internal policy should sign the form to validate the request.
What supporting documents are required?
Include the invoice or transaction ID, a description of the issue, screenshots or logs, and any prior correspondence that substantiates the claim to expedite verification.
How long does processing typically take?
Processing time varies by account tier and complexity; simple requests often complete within 5–10 business days, while disputed or high-value claims may take longer.
How do I correct a submitted form?
Contact the billing team with the tracking ID, supply corrected fields and attachments, and note the changes; maintain prior submission records for audit continuity.
Can a credit be reversed after posting?
Yes. If an error is discovered post-posting, finance may reverse or reallocate the credit following internal controls and documented approver authorization.

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