Cardholder Dispute Information Form

Cardholder Dispute Information Form

  • Cardholder Name
  • Mailing Address

  • We must hear from you no later than 60 days after we sent the first statement on which the transaction appears. You must submit your dispute to us in writing within ten (10) business days.
    Transaction DateMerchant NameTransaction Amount 

  • Please check only one (1) option below. The form must be completed in full or there may be a delay in processing.

  • I have been billed an incorrect amount. My debit card receipt shows:
  • However, I was billed:
  • I have been billed more than once for the same transaction. I authorized only one charge with the merchant for:
  • This transaction was paid for with (Check One):
  • (Please provide a copy of the cash receipt, or the front and back of your canceled check, or a copy of your statement if another card was used.)
  • I cancelled the (check one):
  • Which was charged to my account by this merchant on:
  • I cancelled the charge prior to the transaction date and my cancellation/confirmation number is:
  • Merchandise, which was shipped to me, arrived damaged and/or defective on:
  • And I returned it on:
  • The merchant's response was:
    I have not received the expected services. (Explain in full below).
  • I did not receive a credit that was promised to me by the merchant. I expected the credit on:
  • If applicable: I returned the merchandise on:
  • Via (check one):
  • The tracking number for the returned item is:
  • I have not received the merchandise. Expected date of delivery was:
  • I contacted the merchant on:
  • And the merchant's response was:
  • I certify that the charge(s) listed above were not made by me or a person authorized by me to use my card. In addition, neither I, nor anyone authorized by me, received the goods or services represented by this charge. I understand that in order to move forward with the dispute my card must be closed.
  • At the time the fraudulent transaction(s) occurred, my card was (check one):

  • I noticed my card was lost/stolen on
  • Are you willing to prosecute?
    Are you willing to prosecute?
  • Was law enforcement notified?
    Was law enforcement notified?
  • Please provide a copy with your dispute form.

  • Below, describe in detail the attempts you have made to contact the merchant and what the outcome has been. Include any sales receipts or any other supporting documentation; use a separate sheet for explanation if necessary.
  • MM slash DD slash YYYY
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