Notification of Disputed Transaction

* Indicates Required

• Account Information

  Cardholder Name*

  Email*

  Phone *

  Card Number*

  Card Type*

  Debit Card

  Credit Card

  Card Type is required

• Transaction Information

  Transaction Date*

  Date 1

  Merchant Name*

  Merchant 1

  Dollar Amount*

  Amount 1

  $

  Multiple Transactions

  Date 2

  Merchant 2

  Amount 2

  $

  Date 3

  Merchant 3

  Amount 3

  $

  Date 4

  Merchant 4

  Amount 4

  $

  Date 5

  Merchant 5

  Amount 5

  $

  Date 6

  Merchant 6

  Amount 6

  $

  Date 7

  Merchant 7

  Amount 7

  $

  Date 8

  Merchant 8

  Amount 8

  $

  Date 9

  Merchant 9

  Amount 9

  $

  Date 10

  Merchant 10

  Amount 10

  $

  Date 11

  Merchant 11

  Amount 11

  $

  Date 12

  Merchant 12

  Amount 12

  $

  Date 13

  Merchant 13

  Amount 13

  $

  Date 14

  Merchant 14

  Amount 14

  $

  Date 15

  Merchant 15

  Amount 15

  $

  Date 16

  Merchant 16

  Amount 16

  $

  Date 17

  Merchant 17

  Amount 17

  $

  Date 18

  Merchant 18

  Amount 18

  $

  Date 19

  Merchant 19

  Amount 19

  $

  Date 20

  Merchant 20

  Amount 20

  $

  What was purchased?*

  Merchandise Services

  Type of purchase is required

  Expected Date of Merchandise/Services:*

  Describe in Detail the Merchandise/Services Purchased:*

• Dispute Reason

  Please select ONE item below that best describes the details of your dispute. Please note that it may not be possible to assist you with your dispute unless all relevant information or documents are submitted with this form:*

  MULTIPLE PROCESSING

  I have been billed multiple times (2 or more) for the same purchase.

  The original charge was posted to my account on:*

  in the amount of:*

  $.

  DIFFERENCE IN AMOUNT

  The amount on my sales slip differs from the amount billed.

  The correct amount is:*

  $

  Attached below is a copy of my receipt showing the correct amount*

  PAID BY OTHER MEANS

  The charge(s) was paid by another method.

  The charge was paid by:*

  Cash Debit/Credit Card Check Other

  Payment method is required

  Attached below is a copy of the proof of payment (cancelled check-front and back, receipt or account statement)*

  LATE PRESENTMENT

  The merchant posted a transaction more than 6 months after the transaction date and has caused the account to default.

  I have contacted the merchant and still did not receive resolution. A detailed explanation including my attempt to resolve is detailed below.

  *Please provide additional information or merchant's response in Additional Details section below.

  CREDIT POSTED AS ADDITIONAL DEBIT

  The merchant promised a credit to the cardholder but a second debit was posted to the account.

  I have contacted the merchant and still did not receive resolution. A detailed explanation including my attempt to resolve and proof of credit voucher is detailed below.

  *Please provide additional information or merchant's response in Additional Details section below.

  INCORRECT CURRENCY

  I authorized a transaction, but the merchant posted the sale with an incorrect currency, causing an incorrect amount to be debited.

  I have contacted the merchant and still did not receive resolution. A detailed explanation including my attempt to resolve is detailed below.

  *Please provide additional information or merchant's response in Additional Details section below.

  CREDIT NOT RECEIVED

  I was given a credit slip or refund acknowledgement by the merchant on:*

  Refund Notification Date*

  but the credit has not yet posted to my account.

  Attached below is a copy of the credit slip/refund acknowledgement.

  *If no credit slip/refund acknowledgment given, please provide merchant's response in Additional Details section below.

  CANCELLED TRANSACTION

  I cancelled this recurring transaction with the merchant on:*

  Date of Transaction Cancellation

  No charges after this date are authorized from this merchant.

  If merchandise was purchased, please provide the date you expected to receive merchandise:

  I was advised of the Terms and Conditions of the sale or cancellation policy:*

  Yes No

  Sale or cancellation terms is required

  CANCELLED RESERVATION

  I cancelled this reservation with the hotel/lodging merchant on:*

  The reservation was made for:*

  Were you given a cancellation number?:*

  Yes

  The cancellation number provided to me is:*

  No

  Were you advised of the cancellation policy?:*

  Yes No

  Cancellation policy is required

  Whether a number was given is required

  *Please provide additional information or merchant's response in Additional Details section below.

  MERCHANDISE/SERVICES NOT RECEIVED

  I have not received the merchandise/services by the Expected Date noted above.

  I have contacted the merchant on:*

  Date of Contact

  but a credit has yet to post to my account.

  Was the merchant ununwilling or unable to provide the merchandise/services?:*

  Yes No

  Merchant Willingness Selection is required

  *Please provide additional information or merchant's response in Additional Details section below.

  MERCHANDISE RETURNED

  I have returned the merchandise on:*

  Date Returned

  and requested a refund from the merchant.

  My Return Authorization Number (RAN) or cancellation number is:*

  The merchandise was returned via:*

  USPS FedEx UPS Other

  Return Method is required

  My Tracking Number:*

  *Please provide additional information or merchant's response in Additional Details section below.

  NOT AS DESCRIBED

  The merchandise/services are different from what was ordered or described. I have detailed what was expected, what was received, and indicated my attempt to return below.

  Was the merchandise deemed counterfeit?:*

  Yes No

  Counterfeit status is required

  Please provide information on the entity that indicated merchandise to be counterfeit:*

  Date Entity Notified as Counterfeit:*

  *Please provide additional information or merchant's response in Additional Details section below.

  DEFECTIVE MERCHANDISE

  The merchandise ordered and received was damaged or defective.

  I have contacted the merchant and still did not receive resolution. A detailed explanation including my attempt to return is detailed below.

  *Please provide additional information or merchant's response in Additional Details section below.

  MISREPRESENTATION (Debt Consolidation, Credit Repair, Mortgage Repair/Modification, Credit Card Interest Rate Reduction)

  The terms of sale were misrepresented by the merchant.

  I have contacted the merchant and still did not receive resolution. A detailed explanation of the misrepresentation including evidence, supporting documentation, and my attempt to resolve is detailed below.

  *Please provide additional information or merchant's response in Additional Details section below.

  DELAYED/AMENDED CHARGES (LODGING, VEHICLE/EQUIPMENT RENTAL, ETC.)

  I was billed for additional fees by the merchant which I did not authorize.

  I have contacted the merchant and still did not receive resolution.

  *Please provide additional information or merchant's response in Additional Details section below.

  ATM DISCREPANCY

  The incorrect amount was dispensed from an ATM.

  Were any Funds received?:*

  No funds received Portion of funds received

  Whether funds were received is required

  Total Amount Received:*

  $

  Reason for Dispute is required

  Please attach supporting documents

  Accepted formats: .pages, .doc, .docx, .pdf, .png, .jpg.

  Select files from your computer
  or simply drag & drop them here

  Additional Details (Please provide a detailed description of what was received for Not as Described/Counterfeit/Defective):

• Attempt to resolve

  Did you attempt to resolve with the merchant?:*

  Yes No

  PLEASE FIRST ATTEMPT TO RESOLVE WITH THE MERCHANT BEFORE CONTINUING THIS FORM.

  Whether resolution was attempted with the merchant is required

  Date of most recent contact with merchant:*

  Contact Name:*

  How did you contact the merchant?:*

  Phone Email Letter In person

  Contact method is required

  Please describe the attempt to resolve with the merchant:*

• Signature

  Cardholder Name (type name)*

  Cardholder Signature *

  Clear Signature

  Date*