Credit Cardholder Dispute Form
Credit Cardholder Dispute Form
Credit Cardholder Dispute Form
I am disputing the following transaction(s) for the reason given below and request you to settle the case(s) : DETAILS OF DISPUTED ITEM(S) : TRANSACTION DATE MERCHANT NAME TRANSACTION AMOUNT
Voucher/Refund note/Merchants letter or any form of merchants confirmation that the credit is due to the card account)
I had received defective merchandise/goods and had returned the goods to the merchant. (Attach Credit Voucher/Refund
note/Merchants letter or any form of merchants confirmation that the credit is due to the card account)
Paid by alternate means. First, I gave my card for payment, but later on paid by other means for the same transaction. I Paid
by Cash (attach cash receipt/bill)/ Cheque (attach Cheque receipt/Bank statement)/ other card (attach chargeslip/other card statement) Cancelled Membership/Subscription/Booking. (Attach the proof of merchant acknowledging the cancellation) I ordered goods/services and the same were expected to be delivered by date (dd/mm/yy)___________, but I never received the same. (Attach the proof of merchant acknowledging the cancellation) The transaction amount incurred/authorized by me is for Rs.___________ but I was billed for Rs.__________. (Attach copy of authorized chargeslip) Cash was not dispensed at the ATM but I was billed for the entire amount of Rs._____________. Cash was dispensed partially in the ATM for Rs.___________ but I was billed for the entire amount of Rs.__________. Others (Please explain in detail. Please attach a separate letter if necessary) ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ I declare that above given information is true and correct to my knowledge. I understand that I can be held liable for all charges incurred if dispute raised by me is found invalid. I agree to pay the charges levied by the bank for the same including the cost incurred for investigation of my claim. The Bank may contact me whenever it requires any further information. Email/Phone / Fax: ______________________ __________________________ Cardholder's Signature Date : _______________________________ _______________________________ Add-on Cardholder's Signature (If any)
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