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Charge Back Form

This document is a cardholder dispute form for HDFC Bank. It allows a cardholder to dispute transactions and request chargebacks or credits for various reasons. The form requests details of the disputed transaction such as date, merchant, and amount. It provides checkboxes to indicate the reason for dispute, including duplicate billing, paid by other means, incorrect amount, cancelled transactions, unreceived goods/services, cash not dispensed from ATM, or unauthorized transactions. The form requires the cardholder signature and contact information to declare the dispute information is true to their knowledge. It notes that a retrieval fee may be charged if the disputed transaction is later deemed valid.

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Rajesh Sharma
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© Attribution Non-Commercial (BY-NC)
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318 views

Charge Back Form

This document is a cardholder dispute form for HDFC Bank. It allows a cardholder to dispute transactions and request chargebacks or credits for various reasons. The form requests details of the disputed transaction such as date, merchant, and amount. It provides checkboxes to indicate the reason for dispute, including duplicate billing, paid by other means, incorrect amount, cancelled transactions, unreceived goods/services, cash not dispensed from ATM, or unauthorized transactions. The form requires the cardholder signature and contact information to declare the dispute information is true to their knowledge. It notes that a retrieval fee may be charged if the disputed transaction is later deemed valid.

Uploaded by

Rajesh Sharma
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

To The Charge back unit, HDFC Bank, O-2, I Think Techno Campus, Near Kanjurmarg Station, Kanjurmarg East, Mumbai 400042 Fax: 022-30751580. Card Number A/c Number

Details of disputed item/s: Transaction Date Merchant Name/ATM Location

Transaction Amt

Disputed Amt

I am disputing the transaction(s)listed above for the below given reason and request you to settle the cases. (Please one) *Credit with Hold Funds will be marked only for transactions done at Merchant locations for the below disputes (Cases 1 to 6). If the aforesaid transaction(s) is deemed to be a valid transaction, Credit put to your account with hold funds will be reversed and proof of transactions will be sent to you. 1. Duplicate/multiple billing. I have done only one transaction but I was billed ______(Twice/Thrice etc). (#accepted transaction receipt) 2. Paid by other means. First I gave my card for payment and later on I changed my mind and paid by other means like by cash (#attach cash receipt/bill)/Cheque(#attach cheque receipt/bank statement)/other card (#attach chargeslip/other card statement ). 3. The transaction Amount is Rs__________but I was billed for Rs.__________ (#Attach customer copy of chargeslip/sales slip). 4. Transaction cancelled and I have not received the credit/refund for the same (Attach credit slip/refund note/merchants letter or any form of merchants confirmation that the transaction was cancelled and the credit was due to you). 5. Cancelled membership/Subscription/booking (**Attach the cancellation letter which you sent to the merchant) 6. I ordered goods/services and the same are expected by Date ( dd/mm/yy)_________. But I never received the same. ** I contacted the merchant on Date (dd/mm/yy) ________and his response _____ _____________________________________________________________________. 7. Cash not dispensed in the ATM but I was billed for the amount. 8. Received cash Rs.________ in the ATM but I was billed for the entire amount Rs_______. 9. I have not participated or authorised the above transaction(s). The card was in possession of mine at all times. 10. Others (Please explain in detail. Please attach a separate letter if necessary). ________________________________________________________________________________________ ________________________________________________________________________________________

* Credit with hold funds will not be given for all disputes arising due to misuse and fraudulent usage on
cards being reported as stolen or lost. **For Internet / E-commerce transactions, the customer needs to first contact the Merchant & attempt to resolve the dispute. Declaration: I hereby confirm that the information mentioned above is true and to the best of my knowledge. Cardholders Name Signature Email : : : Place Date : :

Landline / Mobile No :

Please note that a Retrieval Fee of Rs.100/- shall be charged per transaction to your account if the disputed transaction turns out to be valid.

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