Broker Claim Form « Tidewater Marketing Global Consultants, Inc.

Enter Information

Name (Individual / Company)(required)
Contact Person (If Different)
Street Address(required)
Mailing Adress (If Different)
City(required)
State(required)
Zip Code + 4(required)
Taxpayer ID #(required)
Telephone #(required)
Cell Phone #
Facsimile #
Email(valid email required)
# of Passcodes Purchased(required)
Total amount Paid.(required)
Provide pdf copies of Payments (both sides of Cancelled Checks) and Supporting Invoices.(required)
Name of each Tidewater Representative from Whom You purchased Coupns. Please include Address, Telephone #s and e-mail address.(required)
Attach a PDF file listing Each Retailer to whom you Sold Coupons and the Amount you Received.(required)
Amount Claimed(required)
Explain the basis for the amount claimed, including detailed computations, if any.(required)
Other Information Deemed Pertinent
Verification