Your Name Your Pseudo City Code (PCC) Passenger Name PNR # (Record Locator) Ticket Issue Date Type of Refund * Full Partial Are you refunding conjunctive tickets? No Yes How many conjunctive tickets? 2 3 Ticket Number Coupons you are Refunding 1 2 3 4 Ticket Number 2 Coupons you are Refunding for Ticket #2 1 2 3 4 Ticket Number 3 Coupons you are Refunding for Ticket #3 1 2 3 4 Base Fare Refund Due US Tax Refund Due ZP Tax Refund Due AY Tax Refund Due XF Tax Refund Due- Cities/Amounts Do Additional Taxes Qualify for this Refund? (Please specify code and amount) Example YQ 200.00/XR 100.00 Penalty (in U.S. Dollars) Refund or Penalty Waiver? Please add code here Total Amount of Refund * Commission amount being returned (if applicable) (in U.S. Dollars) Additional Comments If you are human, leave this field blank.