Transaction Dispute Form printable pdf download

Transaction Dispute Form

Date: __________________

Name

Card Number

Phone Number

(This is important, to allow us

to get in touch with you for further clarification)

Email ID

(This is important, to allow us to get in

touch with you for further clarification)

Details of the Disputed Item(s)

Transaction Date

Statement Date

Merchant Name

Transaction Amount

Disputed Amount

DECLARATION: I am disputing the transaction(s) listed above for the reason as follows:

Reason for Dispute

Details

Mandatory Documents

Required

Card lost / stolen on ___/___/___ at

_____a.m/p.m and reported the same to you on

Copy of the FIR filed with

Lost / Stolen Card***

___/___/__, at _____ a.m/p.m by way of

Police

____________________________________.

I have been charged twice for the same

Copy of Charge slip

Duplicate Charge

transaction on: _____________. Disputed

showing the actual amount

Amount:_________

ATM Cash Not

A - Cash Not dispensed __________

Copy of the ATM slip

Received

B - Partial amount dispensed by ATM _______

 Cash

Cash Memo/Bank

Paid for Goods by

 Cheque / DD/ Credit card____________

Statement/Payment

Other Means

Date _______

Counterfoil/Card Statement.

Copy of Letter / Email sent

Non-Receipt of

Tickets/ Merchandise not received. Expected

to Merchant to resolve the

Goods or Services

Delivery Date: __________________

issue

Copy of Credit /Refund Slip/

Date of Credit Voucher Issuance:

Credit Not Processed

Cancellation letter from

__________________

merchant establishment.

Confirmation letter / email

Billed for No-Show

Cancellation Date: __________________

received from the merchant

Charge after

Cancellation Number: __________

Copy of Terms &

Cancellation

Conditions from merchant

Incorrect Transaction

Transaction amount incurred was _______, but I

Copy of Charge slip

Amount

have been billed for ______.

showing the actual amount

I have neither incurred nor authorized the

above transactions.

I have incurred one transaction-dated

Unauthorized

Copy of charge slip for the

Transaction(s)***

_______ at the above merchant establishment.

genuine transaction

However I have not incurred or authorized other

transactions listed above at the same merchant.

Primary Cardholder's Signature ____________________________________________

Transaction Dispute Form

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