Customer Dispute Form

CARDHOLDER DETAILS

REASON FOR DISPUTE

I , certify that the information herein provided is true and accurate.

I have examined the charges on my account and I am disputing the following transaction(s) for the reason indicated below:

Please check the most suitable reason that applies to this dispute:

() I certify that the transaction (s) listed were not authorized by me or any authorized users of the account, nor did I grant any person permission to engage in the transaction (s), nor did I benefit in any way from the transaction (s). I therefore do not accept responsibility for same.

() I acknowledge participation in at least one transaction at the mentioned Merchant. However, I certify that I neither engaged in nor authorized the transaction in question. I therefore certify that the signature appearing on the disputed sales receipt is not mine. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

() I certify that the merchandise/service was ordered by me but was never received or was cancelled by me after processing. Or I certify that the item (s) ordered were received by me but was faulty/defective so was returned to the Merchant. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

() I certify that the transaction appears more than once on my Statement; however, I certify that only one transaction was made by me. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

() I certify that I never used, nor have I given any person my consent or authority to use my Card or Pin to withdraw funds from my account. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

() I certify that I attempted to retrieve funds from the ATM and was unsuccessful because the ATM did not dispense cash, retracted the cash or disbursed a partial amount of the full cash amount requested. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

DETAILS OF DISPUTED ITEMS

TOTALS
 
 

COMPLETE THIS SECTION IF YOU ARE DISPUTING THIS TRANSACTION DUE TO NON-RECEIVE OF ITEM (S) PURCHASED OR DUE TO CANCELLATION OF THE ORDER (S):

Upload Any Supporting Documents ( eg. Scans of orders , communications etc. )

You can select multiple files for upload.

I am attaching copies of all pertinent documents to support this claim and I am willing to testify in court on the facts herein contained in this statement.