Customer Transaction Dispute Form

ADVERTISEMENT

The Commercial Bank of Qatar (Q.S.C.)
(
)
PO Box 3232, Doha, State of Qatar
Tel: +974 4449 0000
Fax: +974 4449 0070
Customer Transaction Dispute Form
Acount Details
(please fill in all applicable)
(
)
Cardholder Name
Date
Transaction occured card
Telephone No
Mobile No
Email ID
"Mentioned below are some dispute reasons. Please select the applicable scenario and provide appropriate documentation as indicated. Please note, The Commercial Bank of Qatar will not be able to initiate dispute resolution unless
the relevant documents are submitted along with the dispute form "
Original Transaction Amount
Disputed Amount
S. No
Transaction Date
Merchant Name
(original currency of the disputed transaction)
(QAR Currency)
1
2
3
Note: In case you are disputing more than three transactions; please provide the transaction details in a separate sheet as an Annexure
Dispute Reasons : (Tick The Appropriate)
Unauthorised Transaction
Neither I nor anyone authorised to use my account participated in or authorised the transaction
My card was (circle one of the following choices below):
A. In my possession at the time of fraudulent use
C. Never received
B. Lost/Stolen: Date:__________________
Location:__________________________
D. Others ___________________________________________________________________
Duplicate /multiple
I have been charged multiple times but have authorised only one transaction. The original amount appeared on my ______________ Statement (indicate statement period), a copy of which is enclosed.
Processing
Di erence In Amount
The amount on my sales slip di ers from the amount billed. Attached is my sales slip showing the correct amount The di erence amount disputed is QR ____________
I had cancelled the transaction / services on _________________ (DD-MM-YYYY)
The reason for cancellation: ________________________________________________
Cancelled Transaction
The cancellation numbers/confirmation provided by the merchant is __________________ (proof attached)
Paid By Other Means
I had paid for the transaction by ________________ (specify the mode) for an amount of QR _____________.
Attached is a copy of proof of payment made by other means (Cheque/Cash/through other Credit or Debit Card)
Goods/services Not
I have ordered/booked the goods/services on ________________(DD-MM-YYYY) , but not received the goods/services as on ______________ (DD-MM-YYYY)
Received
I have contacted the Merchant on____________ (DD-MM-YYYY). The merchant’s response to my request for the refund or delivery date is attached herewith.
Note: (The cardholder must attempt to resolve the dispute with merchant and should confirm the same in his/her complaint.)
I was given a credit slip / credit confirmation for an amount of ____________on_________(DD-MM-YYYY) by the merchant.
Credit Not Received
A. The above credit is not yet reflecting on my statement.
B. The credit is listed as a debit on my statement.
(Please attach the copy of the credit slip/ confirmation provided by the merchant)
I am disputing the goods/services received as Defective/Not as described. On the reverse I have detailed what goods/services were expected and what goods/services have been received. I have indicated
Defective
my attempt to return the goods to the Merchant. (* Quality of services / merchandise cannot be disputed)
Merchandise/merchandis
I have received the goods on ________________(DD-MM-YYYY) and returned on ______________ (DD-MM-YYYY) for the reason of ____________________.
e Not As Described
I have contacted the Merchant on____________ (DD-MM-YYYY).
The merchant’s response to my request for the return/refund is attached herewith.
(The cardholder should have returned or made an attempt to return the merchandise and must state so in the dispute.)
Atm Discrepancy
A. ATM did not dispense cash but my account is debited for the amount of ` ________on DDMMYYYY
B. ATM partially dispensed cash for QR __________ but my account is debited for the amount of QR ____________on DD-MM-YYYY.
(Attached is my copy of ATM slip.)
Item(S) Not Recognised
I could not recognise/remember this transaction and I would request you to provide more details about the transaction(s).
Primary Cardholder's
Addon Cardholder's
Signature :
Signature :
Signature Verified
by Sta :
(Please note that signature of the cardholder is mandatory in whose card the disputed transactions occurred)
Kindly submit the duly singed form at your nearest Cb branch or Fax to +974 - 44490070

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 2