Cardholder Dispute Form

Your Information

Name

Mobile Phone

Home/Work Phone

Address

Card Number

Email Address

Description of Loss

Type of Loss

Lost

Stolen

Card was in my possession at the time the transaction(s) occurred

I have examined the charges on my credit card and question the following transaction(s) (attach additional sheets if necessary):

Merchant Name

Amount

Transaction Date

The following explains my dispute:

I received a price adjustment (credit slip) on the above transaction and it has not appeared on my statement. I have included a photocopy of the credit slip.

I certify that only one transaction was made with the above referenced merchant. On my statement, the same merchant has processed a second charge to my account, which I neither participated in nor authorized.

I certify that I participated in the above transact ion, but have not received the merchandise. (Describe your attempts to resolve the matter with the merchant as well as the expected date of delivery on the additional space provided).

I certify that I participated in the above transaction, but have returned the merchandise/cancelled services on

per the merchant's instructions and have not received credit. (Merchant cancellation policies may apply; please provide full details on the additional space provided).

I contacted the merchant on

and canceled the monthly recurring transaction. (Merchant cancellation policies may apply; please provide full details on the additional space provided).

I contacted the merchant on

and canceled my reservation. (Please provide full details on the additional space provided).

My cancellation number is

I was not given a cancellation number.

The shipped merchandise I received is defective. (Describe in the additional space the defect or damage and attempts to return the merchandise, and the merchant's response).

The merchandise/services were. not as described. (If purchase was made over the phone please indicate what was not as described. Otherwise, please provide written documentation as to what was not as described. ie: color, quantity, etc)

I would like a copy of the sales draft. (Reason for request)

I certify that the charge(s) was (were) not made by me or by a person authorized by me to use my card, nor were the goods or services represented by the above transaction received by myself or by a person authorized by me. (Your card will be blocked)

Other. Describe below. Descriptions of transactions should be typed or written clearly. Attach additional sheets if necessary.

In dispute cases except those related to lost/stolen/counterfeit cards, you may be required to make an attempt to resolve the dispute with the merchant prior to filing a dispute. Please describe your attempt to resolve in the following sections: Attempt to Resolve Information:

I have made an attempt to resolve with the merchant.

Yes

Date of contact

Contact Method

Telephone

In Person

Other

Other (describe):

Merchants Response

If no attempt, why not?

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