Dispute Information Form (Page 2 of 2) in pdf

Service not as Described (The service I received was not what I expected based on the description provided by the

merchant)

_____________________________________

What was purchased?

_____________________

Date the service was received:

__________________

Date you cancelled or attempted to cancel the service:

_______________

Was merchandise received with the service?

If yes, please provide the following:

______________

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 service you received was different

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

Credit not Processed (I did not receive credit that was promised to me by the merchant)

_____________________________________

What was purchased?

_________________________________

Expected date of credit:

____________________

Date merchandise or service was received:

__________________

Date merchandise or service was returned or cancelled:

If credit is for merchandise, please provide the following:

______________

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 your reasons for cancellation/return in the

space for additional information below.

Please provide a copy of the return receipt or proof of return, such as a postal receipt if applicable. Please provide any

documentation you have, such as a credit voucher, that supports your claim the merchant promised you a credit.

Non-Receipt of Merchandise or Service (I did not receive the merchandise or service I ordered by the agreed upon

date)

_____________________________________

What was purchased?

_________________

Date you expected to receive the merchandise or service:

_________________

If merchandise, was it to be shipped or picked up?

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

Additional Information (Please provide additional information required for the dispute type and a full description of your

interaction with the merchant from purchase to your last contact. Attach additional pages if necessary.)

________________________________________________________________________________

ote: FIS has final responsibility to determine the correct reason code based on information provided and

investigation results.

Dispute Information Form Page 2

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