Requests For Additional Documentation.: Fax Number: (800) 253-1220

Transaction Dispute Form
This form must be completed and submitted as soon as a disputed transaction is identified. Transaction Dispute forms must be
received within 90 calendar days after the transaction allegedly in error was debited from or credited to the account.
Otherwise your dispute rights might be compromised. Complete all fields in this form. Incomplete forms will delay the dispute
process.
Important Note: This transaction dispute form is not intended to dispute why a transaction was declined or used for submission of
requests for additional documentation.
If you have any concerns or questions with your specific dispute or the dispute process, please contact the phone number on the back of
your card.
Cardholder name Benefit Administrator’s Name:
PNC
Cardholder mailing address Cardholder Phone #
City and state Zip code
Transaction
Card Number Date of Transaction Merchant Name
Amount
Transaction
Card Number Date of Transaction Merchant Name
Amount
REASON FOR DISPUTE- PLEASE CHOOSE ONLY ONE

 1. I did engage in the above transaction: However, I dispute the entire charge or a portion in the amount of $ ______________. I have
contacted the merchant and requested a credit adjustment that has not been received or was not satisfactory. I am disputing the
charge because:
 2. I made a purchase with this merchant previously and was billed correctly for this. However, I have been billed by this merchant for
an additional purchase which I did not make or authorize.
 3. The amount of the sales slip was increased from $__________ to $__________. Enclosed is a copy of my sales slip. No additional
charge was made or authorized to be added to my sales slip.
 4. I contacted the merchant giving them notification of cancellation prior to the date of this transaction. The exact date of the
cancellation was: __________. The cancellation # is: __________.
 5. I certify the charge(s) above was/were not made by me or a person authorized by me to use my card, nor were goods or services,
represented by the above transaction(s) received by me.
Date card lost or stolen: __________ Police Report Number: __________ State: __________
 6. Other or additional charges (for additional space use back of form if applicable):
I acknowledge that all information contained or submitted with this declaration is true.
CARD HOLDER(S) SIGNATURE(S): signature of accountholder is required.
Name Signature Date

Note: Please use a separate sheet of paper using the exact format above if additional dispute explanation is required and/or additional
transactions need to be disputed. Date and signatures are required both on this form and any attachments. Failure to do so could affect
transaction dispute rights.
Fax or mail the completed form to:
Cardholder Services
Fax Number: (800) 253-1220
Cardholder Services
P.O. Box 7235
Sioux Falls, SD 57117-7235
Transaction Dispute Form
Instructions, Required fields, and transaction dispute process
Instructions for Completing the Transaction Dispute Form
1. Complete all fields in the form. Incomplete forms will delay the dispute process.
2. Sign and Date the form.
3. Fax or Mail the form to Cardholder Services (contact information is at the bottom of the form). If you fax this form, please save your
fax transmittal/confirmation. If you mail this form, please contact us to ensure that the form has been received by the 90th day after
the transaction allegedly in error was debited from or credited to the account. Otherwise this could affect transaction dispute rights.
REQUIRED FIELDS
Cardholder name – Name of the cardholder as printed on the front of the Debit Card
Cardholder mailing address – Cardholder’s mailing address
City and state – Cardholder’s mailing address city and state
Cardholder phone # – Cardholder’s primary phone number including area code in case we have questions regarding this dispute
Zip Code – Cardholder’s mailing address zip code
Debit Card number – 16-digit account number printed on the front of the Debit Card
Date of Settled Transaction – Date the transaction posted/settled to the account. A transaction cannot be disputed until it has posted.
Transaction Amount – Total purchase amount for the transaction in question
Merchant Name – Name of the merchant where the disputed transaction occurred
TRANSACTION DISPUTE PROCESS
If you suspect fraud or error on your card:
1. Contact the number on the back of your card immediately.

2. If this is an unrecognized transaction ask the customer service representative to have your card reported as lost/stolen. If your card
is not reported as lost/stolen you may receive a letter instructing you to have your card reported as Lost/Stolen before moving
forward with your dispute.
3. Complete the Transaction Dispute Form and fax or mail to Cardholder Services (contact information on bottom of page 1). It must
be received within 90 days after the transaction allegedly in error was debited from or credited to the account.
4. Your account will receive a provisional credit within 5 business days as long as the Transaction Dispute Form is valid and received
within 90 days after the transaction allegedly in error was debited from or credited to the account.
5. If Cardholder Services requests that you provide additional dispute documentation, it must be received within 20 calendar days
from the date listed on the letter sent to you in order to avoid having the provisional credit reversed.
o Submission of a police report should not be considered a substitute for responding to follow up affidavits received requesting
signatures or other dispute documentation.
6. If the Merchant for the transaction provides adequate documentation to deny your claim (within 45 calendar days of receipt of the
Transaction Dispute Form), then the provisional credit will be reversed and the dispute will be denied.
7. The typical time frame for a disputed transaction to be considered complete with permanent credit on your account is within 90
calendar days from the date the completed Transaction Dispute Form is received.
Important Note: The transaction dispute process is not intended to dispute why a transaction was declined or submission of requests for
additional documentation. Please contact the number on the back of your card if you have any questions.

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Transaction Dispute Form

Cardholder name Benefit Administrator’s Name:

City and state Zip code

REASON FOR DISPUTE- PLEASE CHOOSE ONLY ONE

CARD HOLDER(S) SIGNATURE(S): signature of accountholder is required.

Name Signature Date

TRANSACTION DISPUTE PROCESS

If you suspect fraud or error on your card:

1. Contact the number on the back of your card immediately.

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