Disputed Transactions Form Page 4
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4section 5 – your Declaration.
By ticking this box, I, and any additional cardholders confirm that the information I’ve provided is true to the best of my
knowledge. That, I/we are happy for Capital One to contact the merchant, my bank and relevant parties to discuss the
dispute, disclosing account details and information where needed.
D D
M M
Y Y Y Y
account holDer’s signature (requireD):
Date:
Please tick the box.
REMEMBER:
BEFoRE YoU SEND US YoUR FoRM.
Make sure you have:
Checked all sections are completed correctly
If you complete the form incorrectly, or don’t provide a detailed explanation where required, there may be a delay
in processing your dispute
Sent us all the documents we’ve asked for
It may not be possible to help you with your dispute unless all required documents are submitted with the form
Complete the signatory box
We will review your form and documents to assess what’s happened. Then we’ll give you an update within
21 days, either by letter, email or phone.
Return Information
Please return this completed form along with any supporting documentation to one of the following:
Capital one, Po Box 9766, Nottingham NG2 9HY
PoST
EMAIL
As email is not secure, we can’t guarantee that any emails you send
to us will not be intercepted or interfered with by third parties.
0115 843 3657
FAx
Did you know: You can use your smart phone to take photographs of this form and supporting documentation
and send them to the email address above. These images will be accepted as long as they are clear and all text is
legible. Please do not resize any images.
Emails that are sent should not exceed 10MB each, but you can send multiple emails if required. You’ll get a
confirmation email from us once we’ve received your email.
92009239/DISPUTRA/0914/WEB
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