Scribd
Upload
32 views3 pages

I2c Generic Dispute Form

Uploaded by

saisrujan816
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
32 views3 pages

I2c Generic Dispute Form

Uploaded by

saisrujan816
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 3

Customer Statement of Disputed Transaction

Please complete either section 1 or section 2 below. Use a separate form or additional pages to
document each dispute. Mail to: Cardholder Services, 100 Redwood Shores Parkway, Suite 100
Redwood City, CA 94065 Or fax to: 650-242-4112 Or email: [email protected] If you have any
questions, please call the number printed at the back of your card.

Your Name:
Card first 4 digits: Card last 4 digits:

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):

a. I requested $ from the ATM however I received $ . I am disputing the amount of


$ as this amount was not received.

b. 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.

e. 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.

f. 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:
.

g. 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:

Cardholder Signature: Date:


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

You might also like