Fillable Disputed Transactions Form (Page 2 of 4) in pdf

section 3 – Which reason best Describes your Dispute(s)?

Please tick the one box that best matches your dispute. Or, if you have more than one, tick the boxes that

best match each dispute.

Please be sure to send us any documents we require, highlighted in blue below – copies and photographs

✔

are fine.

I have cancelled the regular payment / subscription / membership / annual renewal

I cancelled this on

____ /____ /______

Please send proof of cancellation where possible, for example,

confirmation from the merchant.

YYYY

I have been overcharged

I only agreed to pay £ ___________________

Please provide proof, for example, a copy of your receipt or

invoice showing the amount you agreed to pay.

I have paid by other means

I have paid by (please tick one)

Please send us at least one of the following:

• A receipt for cash paid

Cash

Credit / Debit Card

• A copy of the cheque (front and back) from the bank

Cheque

Other

• A copy statement showing the card transaction

• Any other document showing how you paid

• Please provide further information in Section 4

I have not received the goods/services/tickets

Note for this Dispute: Please allow 30 days from the transaction date to pass prior to returning this form. For event tickets (e.g.

concert) we cannot dispute the transaction before the event date, unless you can provide proof you will not receive the tickets or

the event has been cancelled.

Please include a copy of your receipt or invoice. In Section 4,

The latest date I was expecting to receive this was:

____ /____ /_______

provide a detailed description of what you ordered.

YYYY

I have not received the correct amount of cash from the cash machine

Amount not received: £___________________

None required

I have not received my refund

I expected a refund of £___________________

Please send us a copy of either:

• A refund receipt with card number/amount/date of refund

• The merchant’s return and/or cancellation terms

I cancelled my goods/services on

____ /____ /_______

(if applicable)

YYYY

The goods/service were faulty or different to what I ordered

I received the goods/service on

____ /____ /_______

Please provide us with copies of:

• Photographs

YYYY

• Proof of return and/or cancellation

In Section 4, please provide details of what is wrong with

• A report from a relevant independent specialist

the goods/service.

on their own letterhead

• A copy of the receipt/invoice

I do not recognise the transaction(s)

I/we had our cards when the transaction happened. I have tried to

None required

contact the merchant without success.

None of the above

In Section 4, please provide full details of your dispute.

Please provide copies of any paperwork or documents

that will support your dispute.

Disputed Transactions Form Page 2

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