Disputed Transactions Form

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DisputeD transactions form.
Please fill in this form and send us any relevant documents that will
!
Before we look into
help us find out what has happened and try to resolve things for you.
your dispute, you first
need to contact the
Please complete all 5 sections.
merchant to see if
you can resolve the
problem.
section 1 – your contact Details.
Account holder name:
House name or number:
Post code:
Last 4 digits of your account number
How can we contact you?
We’ll contact you by post, but please let us know if we can also get in touch by phone or email.
Telephone number (we’ll only call between 9am-4pm)
Email address:
section 2 – your DisputeD transaction(s).
Please add the transaction(s) to the table below. If you run out of space, please use Section 4.
Transaction
Merchant name
Transaction
Disputed amount
date
(as shown on statement)
amount
(if different)
1
2
3
Before we look into your dispute, you first need to contact the merchant to see if you can resolve the problem.
Please provide details of who you contacted, when, and what happened.
1

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