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Merchant Dispute Form

The Merchant Dispute Form is designed for customers to report and dispute transactions with specific details about the disputed items. Customers must select a reason for the dispute, such as duplicate billing or non-receipt of goods, and provide necessary documentation. A declaration is included for customers to confirm the accuracy of the information provided.

Uploaded by

Pushpendra Chaudhary
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14 views1 page

Merchant Dispute Form

The Merchant Dispute Form is designed for customers to report and dispute transactions with specific details about the disputed items. Customers must select a reason for the dispute, such as duplicate billing or non-receipt of goods, and provide necessary documentation. A declaration is included for customers to confirm the accuracy of the information provided.

Uploaded by

Pushpendra Chaudhary
Copyright
© © All Rights Reserved
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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Merchant Dispute Form Date:

A/c Number

Details of disputed item/s:


Transaction Ref Transaction Date Merchant Name Transaction Amt Disputed Amt
No.

I am disputing the transaction(s) listed above for the below given reason and request you to settle
the cases. (Please select one)

1. Duplicate/multiple billing. I have done only one transaction but I was billed ______(Twice/Thrice etc).

2. The transaction Amount is Rs__________but I was billed for Rs.__________

3. Transaction cancelled and I have not received the credit/refund for the same (Attach refund note/
merchant’s letter or any form of merchant’s confirmation that the transaction was cancelled and the credit
was due to you).

4. Cancelled membership/Subscription/booking (**Attach the cancellation letter which you sent to the
merchant)

5. 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 ______
_________________________________________

6. Others (Please explain in detail. Please attach a separate letter if necessary).


________________________________________________________________________________________
________________________________________________________________________________________

**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.

Customer Name: IPPB official Name


Signature Emp id and Branch Name
Email: Signature and Seal
Contact No:

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