Intake Form
Request for Account and Business Information
1. Account Details
A. Payment Processor or Bank:
Specify the name of the payment processor or financial institution managing the account and
holding the funds.
B. Date of Account Opening:
Provide the exact date when the account was created.
C. Account Holder Information:
For individuals: Full name. Passport or ID number is required only if you wish to
engage with our firm and appoint us as legal representatives.
For companies:
Registered business name, registered office address, and company registration
number.
Identity of the company representative (either a director or shareholder). Passport or
ID number is required only if you wish to engage with our firm and appoint us as legal
representatives. This information will be used to draft the power of attorney.
D. Account ID:
Provide the unique identifier or account number linked to the account.
E. Website Used Through the Payment Processor:
Specify the URL of the website associated with the payment processor account.
F. Associated Bank Account Liquidity:
Indicate approximately how much is available as liquidity in the bank account associated with the
payment processor
2. Suspension Information
A. Date of Account Suspension:
Specify the exact date when the account was suspended.
B. Reason for Suspension:
Include any explanation or details provided regarding the suspension.
C. Suspension Emails:
Attach copies of any suspension-related communications sent to the account holder.
3. Financial Information
A. Amount of Money Blocked:
Specify the total amount currently withheld in the account.
B. Monthly Revenue Processed (last 6 months):
Provide the amount of revenue processed for each of the last six months (broken down by month).
C. Last Payout Date:
Indicate the date of the last payout to the account holder’s bank.
D. Website Linked to Account:
Specify the URL of the website associated with the account.
E. Average Price per Item:
Provide the average transaction amount processed through the account.
4. Dispute and Chargeback Information
A. Total Number of Disputes (All-Time):
Specify the total number of disputes received since account inception.
B. Disputes Won:
Provide the total number of disputes resolved in your favor.
C. Disputes Lost:
Provide the total number of disputes resolved against you.
D. Total Number of Refunds:
Specify the total number of refunds issued since account inception.
E. Total Value of Disputes:
Provide the cumulative value of all disputes (in monetary terms).
F. Total Value of Refunds:
Provide the cumulative value of all refunds issued.
G. Dispute Rate (Monthly, Last 6 Months):
Provide the percentage of disputed transactions per month for the last six months.
5. Fulfillment and Service Delivery
A. Service Delivery (for digital services):
Have you provided the service?
• If yes, specify the number of services provided.
• If no, indicate how many services have not been provided and explain why.
B. Order Fulfillment (for physical items):
Have you fulfilled the orders?
• If yes, specify the number of orders fulfilled.
• If no, indicate how many orders have not been fulfilled and explain why.
6. Account Activity
A. Summary of Account Activities:
Provide a detailed overview of the account’s primary purpose, transaction types, and any notable
activity patterns.
7. Compliance and Supporting Documents
A. Compliance Documents:
• Business license or registration certificate.
• Tax identification number.
• Supplier agreements or contracts.
• Logistics and shipping agreements.
B. Proof of Fulfillment for Disputed Transactions:
Attach relevant documentation, such as tracking information or proof of delivery.
7. Compliance and Supporting Documents
A. Compliance Documents:
• Business license or registration certificate.
• Tax identification number.
• Supplier agreements or contracts.
• Logistics and shipping agreements.
B. Proof of Fulfillment for Disputed Transactions:
Attach relevant documentation, such as tracking information or proof of delivery.
8. Risk Mitigation and Fraud Prevention
A. Fraud Prevention Measures:
Describe any measures in place to prevent fraud (e.g., ID verification, transaction monitoring).
B. Refund and Return Policies:
Attach or summarize policies related to refunds, returns, and cancellations
9. History of Deactivation or Account Restraints
A. Prior Deactivations or Restraints:
Is this the first time the account holder has been subject to deactivation or account
restraint by any payment processor?
If no, please provide:
The name of the payment processor(s).
The email(s) associated with the account(s).
10. Customer and Reputation Management
A. Customer Satisfaction Metrics:
Include details like Trustpilot score or similar ratings.
B. Communication Logs:
Provide logs of customer communications related to disputes or complaints.