Dispute Information Form printable pdf download

Dispute Information Form

Mail to: Certegy Customer Service,P.O. Box 30495,Tampa, FL 33630 Or Fax 727-570-8810

Card #:

Cardholder Name: (please print)

First:

Last:

Please check only one statement that pertains to the dispute or fraud claim being filed and provide the information

requested. The templates below assume the cardholder’s perspective.

Unrecognized (I am not sure if I made this transaction)

Please describe your attempt to resolve this dispute with the merchant in the space for additional information below.

Incorrect Amount (I was billed the wrong amount)

_______

What was the amount you should have been billed?

(Please provide a receipt if available)

_____________________________________

What was purchased?

Please describe your attempt to resolve this dispute with the merchant in the space for additional information below.

Duplicate Charge (I have been billed more than once for the same transaction)

_____________________________________

What was purchased?

Please provide a copy of the statement and identify which charge is valid and which is a duplicate.

Paid by Other Means (I paid for this transaction via another payment method or credit card)

_____________________________________

What was purchased?

__________

Paid by:(Circle One) Check

Cash

Another Credit Card

Other

Please describe your attempt to resolve this dispute with the merchant in the space for additional information below.

Please provide a copy of your cash receipt, the front and back of your cancelled check or a copy of your statement if

another credit card was used.

Cancelled (I was charged for something I previously cancelled)

_____________________________________

What was purchased?

___________

Were you advised of the merchant’s cancellation policy?

____________________________________________

If so, how were you advised?

________

What was your method of cancellation? (Circle One) Phone

Mail

Other

_________________

Date of cancellation:

____________________

Cancellation number and/or name of person you spoke with:

Please describe your attempt to resolve this dispute with the merchant and your reasons for cancellation in the space for

additional information below.

If you cancelled by phone, please provide a copy of the telephone bill reflecting the call if available. If you cancelled by

email, please provide a copy of the email correspondence.

Merchandise not as Described (The merchandise I received was damaged, defective, or not what I ordered)

_____________________________________

What was purchased?

_____________________

Date the merchandise was received:

___________________

Date you returned the merchandise or made it available for pick up:

_____________________

Return authorization number or cancellation number if available:

_____________________

Tracking number for returned merchandise:

Please describe your attempt to resolve this dispute with the merchant and how the merchandise you received was

different from what was described in the space for additional information below.

Dispute Information Form

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