Scribd
Upload
8 views

DisputeFormUpdateWord 2

The document is a Customer Statement of Disputed Transaction form, allowing cardholders to dispute unauthorized charges on their account. It requires details about the transaction, the cardholder's possession status of the card, and any communication with the merchant. The form also includes sections for various types of disputes, including unauthorized transactions, incorrect amounts, and issues with received merchandise.

Uploaded by

drewlindsey97
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
8 views

DisputeFormUpdateWord 2

The document is a Customer Statement of Disputed Transaction form, allowing cardholders to dispute unauthorized charges on their account. It requires details about the transaction, the cardholder's possession status of the card, and any communication with the merchant. The form also includes sections for various types of disputes, including unauthorized transactions, incorrect amounts, and issues with received merchandise.

Uploaded by

drewlindsey97
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

Customer Statement of Disputed Transaction

Your Name: ___________________________________________ Card #: ____________________________________________

Transaction Date Merchant Name Post Date Amount

Transaction(s) Description: (as appears on your statement)


________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
_______________________________________________________________________________________________________
________________________________________________________________________________________________________
_ ________________________________________________________________________________________ ______________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
□ 1. I certify that the charge(s) listed above was (were) not made by me nor a person authorized by me to use my card. I did not
receive any goods or services from this transaction nor did any person authorized by me. My card was (please select one)

□ IN MY POSSESSION ☐ LOST
☐ STOLEN

Do you know who made these transactions? ☐YES ☐NO


If YES, who do you think made or authorized these transactions?
___________________________________________________
What is your relationship to this person?
______________________________________________________________________ Please list other items that were
lost or stolen (if any):_________________________________________________________

When was the last time you used your card?


Date: __________________
Time: __________________
Merchant Name or ATM Location: ________________________________________________________________
Amount: $______________

Where do you normally store your card?_______________________________________________

Where do you normally store your pin number? _________________________________________

Have you given permission to anyone to use your card? (Select one) ☐NO
☐ YES (If Yes, complete the following)
Name: __________________________________

Relationship: _____________________________

□ 2. Although I did engage in the above transaction (complete ONE of the following statements and provide as much detail
as possible to support your statement):

1. I requested $__________ from the ATM however I received $___________. I am disputing the amount of $________
as this amount was not received.
2. The dollar amount of the sale was increased from $ _____________ to $ _____________ I am enclosing a copy of my
debit card sales receipt, which reflects the correct dollar amount.

c. I dispute the entire charge or a portion of it in the amount of $ _____________. I have contacted the merchant and a credit
has been applied to my account. (Please provide details of the circumstances surrounding this transaction and your calculations
used to derive the correct amount, if amount is less than the total billed to your account.)

d. I have never received the merchandise. I expected to receive it during the week of _____________ (date.) I have since
contacted the merchant and asked that a credit be applied to my account.

5. All or part of the shipped or delivered merchandise was defective or damaged when received. I returned the
merchandise on _____________ (date) but have not received a credit for the amount of $ _____________. I am
enclosing a detailed statement describing the defects of the merchandise and am enclosing a copy of my proof of
return list of the merchandise received, the items returned, and the cost of each item.
6. The above transaction is a duplication of an authorized transaction that took place on _____________ (posting date.)
The reference number of the authorized transaction as shown on my card statement is: ________________________.
7. I am enclosing a detailed explanation of the reason(s) the merchant was not able or willing to provide the requested
merchandise/services. I am also providing details of my attempts to resolve this matter with the merchant, including
date(s) and the merchant’s response(s).
□ 3. I received a credit slip, but it was applied to my account as a charge. I am enclosing a copy of this credit slip. □ 4. I
received a credit slip, but it has NOT yet been applied to my account. I am enclosing a copy of this credit slip.

□ 5. I guaranteed a hotel reservation for late arrival and subsequently cancelled it on _____________ (date) at
____________ (AM/PM.) I was given the following cancellation number: _________________________

□ 6. Other reason:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

□ 7. Written description of reason for dispute (Mandatory). Please write out exactly why you want to dispute the charges
including any timelines of communication with the merchant along with documentary evidence (if any) to show that the
charges were incorrect. Please note for unauthorized dispute charges you need not contact the merchant but can still provide a
timeline of what you were doing when the charges happened and if you lost your card etc.

Cardholder Signature: __________________________________________ Date: __________________

Contact number: ______________________(During the hours of 8am-5pm CST)

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy