Procurement Card Dispute Form printable pdf download

PROCUREMENT CARD DISPUTE FORM

CARDHOLDER NAME: __________________________ VISA ACCT # (Last 4Digits) __________

MERCHANT NAME: ____________________________ AMOUNT:________________________

TRANSACTION DATE: _________________________ POST DATE:______________________

Dear Cardholder,

This form has been forwarded to you for your convenience. If you need additional space please use the reverse side. Regulations

regarding your dispute require that you notify us in writing within 60 days of the bank date of the transaction. Attempts should be made

with merchant to resolve the dispute before notifying your Procurement Card Administrator. Any response received after the above

mentioned time frame may result in our inability to assist you with your dispute. Please fax your dispute notification to:

1-859-323-1954.

Dipsute forms may also be emailed to procard@email.uky.edu.

CHECK & COMPLETE THE ONE THAT BEST DESCRIBES YOUR DISPUTE & PROVIDE ALL REQUESTED DOCUMENTATION

____ I have been billed more than once for the same transaction. I authorized only one charge with this merchant for

$________. Please provide the date of the previous charge: _____________.

____ I have been charged for a purchase that was paid for by other means. (Other credit card, Check, Etc.) Attach a

copy of the other method of payment that verifies purchase was paid for by other means.

____ I have been billed for the wrong amount on my account. My credit card receipt shows $__________. However, I

was billed $__________. Attach a copy of receipt showing correct amount.

____ I did not authorize this charge. Describe, in full, attempts made to contact vendor or attach email

communications.

____ Merchant was to issue credit for goods returned on ____________. This credit has not posted to my account.

Attach a copy of credit receipt received from merchant / or copy of returned mail receipt.

____ I have not received the Services/Merchandise I ordered. The Service/Delivery date was____________. Explain

all details, including your attempt to resolve with the merchant.

____ I attempted to return merchandise but the merchant refuses to accept it. Explain reason for return, Give

Merchant’s response & provide copy of original return mail receipt.

____ I Canceled the Service on _____________. Cancellation #______________.

____ I have contacted the merchant to resolve my dispute about the quality of services or goods and am still not

satisfied. Describe dispute fully, in detail. Include all documentation that supports your claim.

J. ____ I have resolved my dispute with the merchant.

_______________________________

___________________________

CARDHOLDER SIGNATURE

DATE

Procurement Card Dispute Form