Cardholder Dispute Form printable pdf download

CARDHOLDER DISPUTE FORM

Thank you for contacting us regarding a dispute on your debit card. Please use this form to explain the details of your

dispute. You may place additional details on the second page.

Cardholder Name __________________________ Card number ______-________-________-_______

Merchant Name ___________________________Amount ___________ Transaction date____________

Please choose the ONE category that best describes your dispute:

____

I did not participate or authorize this transaction. (select statement and

SAFE/Fraud Reporting option below)

____ My card is in my possession

____ My card was lost or stolen at the time of transaction.

SAFE/FRAUD REPORTING

Upon initiating any fraud-related chargeback (reason codes MC 4837, 4840, 4847 and Visa 81, 83, 57), the

appropriate fraud reporting option must be chosen below: (financial institution should assist with selection)

____

00 - Lost Card: Cardholder asserts card is lost

____

01 - Card Stolen: Cardholder asserts card has been stolen

____

02 - Card Not Received: Cardholder asserts that he never received the card in the mail.

____

03 - Fraudulent Application: Cardholder asserts that he never completed an application for the card

(There are no chargeback rights for this issue.)

____

04K - Counterfeit Convenience Check

____

04N - Counterfeit PIN Not Used: Cardholder still has card in possession and transaction is card

present. NOTE: Not to be used on MCC 5542.

____

04P - Counterfeit PIN Used

____

05 - Account Take Over: Cardholder asserts that an unauthorized person contacted the bank and had

the address and other information updated to his own. (There are no chargeback rights for this

issue.)

____

06 - Fraudulent Use (MOTO, CNP): Cardholder did not authorize or participate in a mail/phone/e-

commerce transaction. Can also be used for key-entered transaction when another code does not apply.

____

07 - Imprinting of Multiple Drafts: For reason codes MC 4840 and Visa 67. Verify use based on

cardholder documentation, status of card and transaction type.

_____ I do not recognize this transaction.

_____ I paid for this purchase another way, but it still posted to my statement. I have provided:

A cash receipt _____

Copies of both sides of a canceled check _____

The credit/debit card statement where the valid charge appears _____

(Please note one of the above is required before Fifth Third can assist with your dispute.)

_____ This charge posted to my account twice, but I only authorized one purchase. The valid charge posted on

___________. My credit cards are still in my possession.

_____ The charge posted to my account for an amount different from the amount on my receipt.

I have/have not (circle one) enclosed a copy of my receipt showing the difference.

_____ I have not received expected goods or services. The expected date of delivery/completion was _______. I have

contacted the merchant and the response was ____________________________________________.

(Please place additional details of this dispute on the second page of the form.)

_____ The merchandise received was not as described, poor quality, damaged, or unsuitable for the purpose intended.

I returned (or attempted to return) the merchandise on _______. I have contacted the merchant and their

response to the return was ________________________________________________________.

(Please provide details of what was wrong with the merchandise on the second page of the form, and include

proof the goods were returned to the merchant, such as a tracking number.)

_____ I have returned merchandise to the merchant. A copy of my credit slip is enclosed.

Cardholder Dispute Form

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