Dispute Form On Back Of Credit Card Statement printable pdf download

DISPUTED TRANSACTIONS

Rev. June/2011

DISPUTE FORM ON BACK OF CREDIT CARD STATEMENT

What To Do If You Think You Find A Mistake On Your Statement

If you think there is an error on your statement, write to us at:

Card Services, P.O. Box 498181, Cincinnati, OH 45249-9860.

You must contact us within 60 days after the error appeared on your statement. You must notify us of any potential

errors in writing. You may call us, but if you do we are not required to investigate any potential errors and you may

have to pay the amount in question.

While we investigate whether or not there has been an error, the following are true:

We cannot try to collect the amount in question, or report you as delinquent on that amount.

The charge in question may remain on your statement, and we may continue to charge you interest on that

amount. But, if we determine that we made a mistake, you will not have to pay the amount in question or any

interest or other fees related to that amount.

While you do not have to pay the amount in question, you are responsible for the remainder of your balance.

We can apply any unpaid amount against your credit limit.

Please do not mail with your payment – send in a separate envelope to the address on your bill.

Your Name: __________________________________________________________________________

Account Number: ____________________________________________________________________

Transaction Date: _____________________________________________________________________

Amount In Dispute: $__________________________________________________________________

Reference Number: ___________________________________________________________________

Merchant Name: _____________________________________________________________________

I have examined the charges made to my account and dispute the time listed above for the following reason(s):

1a. I do not recognize the charge listed above nor do any persons authorized by me to use my card. No goods or

services represented by the above transaction, to the best of my knowledge, have been received by any

authorized person to use the card.

1b. I certify the above charge is unauthorized. I have reviewed the above charge and it was not made by me or

any person authorized by me. No goods or services represented by the above transaction was received by me or

any person authorized by me.

2. I have not received the merchandise which was to have been shipped to me. I have written the Merchant to

request credit. Enclosed is a copy of the letter.

3. Although I did engage in the above transaction, I dispute the entire charge or a portion in the amount of

$__________. I have contacted the Merchant and requested a credit adjustment. I either did not receive the

credit,

was

unsatisfactory.

disputing

the

charge

because:

_________________________________________________________________________________________

4. I certify that the charge above was single transaction, but was posted twice in error to my statement. I did not

authorize the second transaction. (Please note on which dates the sales in question were posted to your

account.)

5. I returned the merchandise on (date) because __________________________________________________

6. Other __________________________________________________________________________________

Note: Continue on a separate page if necessary.

PLEASE KEEP THE ORIGINALS FOR YOUR RECORDS AND SEND COPIES.

Cardmember Signature

________________________________________________________________________________

Co-Applicant Signature

________________________________________________________________________________

Date ____________________________________________________________________________

Dispute Form On Back Of Credit Card Statement

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