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CARDHOLDER DISPUTE FORM-Gift 060910

This 3 sentence summary provides the essential information from the Cardholder Dispute Form document: The form allows cardholders to dispute transactions on their account that they believe to be in error, and requires attempts to first resolve disputes directly with merchants. It provides instructions for cardholders to identify disputed transactions and notify the issuing bank in writing within 60 days. The form collects personal and transaction details to process disputes and allows selection of dispute reason types to submit to the bank.

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Joseph Strickler
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574 views2 pages

CARDHOLDER DISPUTE FORM-Gift 060910

This 3 sentence summary provides the essential information from the Cardholder Dispute Form document: The form allows cardholders to dispute transactions on their account that they believe to be in error, and requires attempts to first resolve disputes directly with merchants. It provides instructions for cardholders to identify disputed transactions and notify the issuing bank in writing within 60 days. The form collects personal and transaction details to process disputes and allows selection of dispute reason types to submit to the bank.

Uploaded by

Joseph Strickler
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CARDHOLDER DISPUTE FORM

This form has been provided for your convenience. If you believe that a transaction on your account is in error you
can use this form to dispute the transaction in question. Please be advised that Visa requires that attempts be
made to resolve your dispute with the merchant before notifying us.

So that we may serve you better, please let us know immediately that you are planning to dispute a
transaction by identifying the transaction online (www.giftcardmall.com/mygift) or through our automated
response toll-free number 1 (888) 524-1283.

In order to process your dispute, regulations require that you notify us in writing within 60 days from the
statement date of the disputed charge. Any response received after this time frame will not be processed.

Please complete and mail or fax a copy of this form along with any supporting documentation to:

Mailing Address: Fax Number:


Customer Service Toll-Free: 1 (877) 781-5159
Department 6220
5918 Stoneridge Mall Road
Pleasanton, CA 94588

PLEASE DO NOT ALTER THE WORDING ON THIS FORM

PERSONAL INFORMATION
(Please fill this section out completely. Failure to do so will result in a delay of your claim resolution.)

Your Name: ____________________________________ Card Account Number: ___________________________


(16 Digit Card Number)
Telephone Number: ______________________________ Best time to call:________________________________

Address Line 1: ________________________________________________________________________________

Address Line 2: _____________________ City: ______________________ State: _____ Zip Code: ____________

Email Address (optional): ________________________________________________________________________

Transaction Information (please refer to your statement for assistance)

Transaction Date: _______________________ Posting Date: ___________________

Amount $: _____________________________Disputed Amount $:______________

Merchant Name: ________________________Reference Number: ______________

Disputing more than one item? Yes ___ No ____

If Yes, then this is number ___ of ___ (e.g. 1 of 3) ONLY ONE TRANSACTION PER FORM

Select Type of Dispute (Check only one)

Do not recognize – Please attempt to contact the merchant prior to disputing the charge. Merchants often
provide telephone numbers next to their name on your statement.
 When did you contact the Merchant? (mm/dd/yy) ____/____/____
Charged twice for the same transaction – I certify that the charge in question was a single
transaction, but was charged twice to my account. I did not authorize the second transaction.
 Sale # 1 (Valid Transaction) $________________ Reference #: ______________
 Sale # 2 (Invalid Transaction) $________________ Reference #: ______________

Cancellation (hotel, good, services, …) – Please enclose copy of letter, email, or fax informing the merchant
of cancellation.
 Date of cancellation ________________ Cancellation # _____________________________
 Reason for cancellation ______________________________________________________

Merchandise was returned - Please attach signed copy of proof of return.


 Reason for returning ______________________________________________________
 If you are unable to return the merchandise, please explain ________________________
_______________________________________________________________________________

Merchandise not received - Please notify the merchant of non-receipt.


 I have not received merchandise that was to be shipped or picked up on (mm/dd/yy) ____/____/____
 I have asked the merchant to credit my account No ____ Yes ____
 If Yes, when? ____/____/____

Merchandise shipped was either damaged or defective - You must explain in detail how the merchandise
was damaged or defective, provide proof and attempt to return the merchandise prior to exercising this right.
 I have asked the merchant for a credit to my account No ____ Yes ____
 If Yes, when? ____/____/____

Overcharged for a transaction - Please include a copy of the signed sales receipt.
 The amount was increased from $ ________ to $ ________

Credit posted as a sale - Please attach a copy of the credit slip and the original sales slip.

Credit not posted to account - Please enclose a copy of the credit slip or notice of credit from the merchant
and a detailed explanation of your dispute. The merchant has 30 days to credit your account.

Transaction paid by other means - You must provide proof of paid by other means such as a copy of the
cancelled check (front and back), a cash receipt, or a statement from another credit/debit card account.

Service Dispute - Please describe the nature of your dispute and your attempts at resolution on a separate
sheet of paper and attach to this form. Include copies of second opinions from a certified professional,
repair bills, contracts or other supporting documentation.

Unauthorized charge - I certify that I did not authorize or participate in this transaction with the above-
mentioned merchant, nor did I authorize anyone else to use my card. To use this option, you must report your
card lost or stolen immediately. If you have not, please call 1 (888) 524-1283.

Other - Please enclose a DETAILED description on a SEPARATE SHEET and attach it to this form.

SIGNATURE REQUIRED _____________________________________ DATE___________________

Please keep the original for your records

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