Sample Credit Dispute Form (Fillable)

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DISPUTE FORM
Fax
(Direct)
+971 4 369 6916
P. O. Box 28028
Fax
(Priority Banking)
+971 4 369 6989
Card Operations
Call us on
+971 600 5222 88
Dubai – UAE
Kindly fill in this form completely if you are disputing the transaction(s) posted on your statement. Your duly filled and signed
form must be sent to us by fax along with all the supporting documentation. All disputes should be reported to the Bank
within 30 days from the statement date in which the transaction(s) appear. After the lapse of 30 days from your statement
date, it will be construed that all transactions posted in the statement are acceptable and are in order.
Card Number:
Cardholder’s Name
S. No
Transaction Date
Merchant Name (as it appears on the cardholder’s
Billed Amount
statement)
1
2
3
Use additional forms if required for more transactions.
I received my statement dated ________________________ and observed that the above transaction(s) is/are incorrect.
Therefore, I am disputing these transactions for the following reason(s):
I have been billed more than once for the same transaction. I authorise only one charge with the merchant
________________________________for the amount of AED______________ dated_________________________.
I have paid the above transaction(s) amount by __________________________ (payment proof enclosed).
I have cancelled my reservation / recurring transaction / subscription on ____________________ and the
cancellation number is _______________ (enclosed is the cancellation advice as per merchant terms & conditions).
Cash / Goods / Services have not been received by me (enclosed: (a) Merchant sales and delivery terms. (b) My
complaint letter to the merchant about the non-receipt of Cash / Goods / Services).
The amount billed to my card is different from the amount that I had authorised. (Enclosed are copies of the sales
slips).
I confirm that I have participated in the transaction(s) for_____________, dated ______________ but I have certainly
not participated in the transaction(s) for _________________, dated __________________ at ____________________.
Credit / Refund for the above transactions has not been processed (enclosed is the refund/credit voucher).
I have tried to withdraw cash from the___________________________ Bank ATM but the cash was not dispensed
(enclosed is ATM slip copy).
I only received (amount) ________________ for ATM withdrawal but my Card was debited for_________________.
I have neither participated nor authorised the above transaction(s).
Select one of the below options:
The Card was in my possession at the time of transaction and I have attached my passport copy (All Pages) to
facilitate the Dispute Process as per Visa/Master International Operation regulations
The Card was not in my possession at the time of transaction
If none of the above reasons apply: Please provide a complete description of the dispute along with your
attempted resolution with the merchant. Also enclose any documentation that may support your claim.
.
Additional comments _____________________________________________________________________________________
I understand that the Bank is authorised to debit my account for the sales voucher request fees (as applicable) and any other related
charges that the bank may incur in respect of the disputed transaction(s). Further I endorse that I shall stand by the truth of this
statement for subsequent legal enquiries by the Bank/law enforcement agencies (if required). I understand that the investigation may
take 180 days or more for resolution and the Bank reserves the right to provide/ reverse any temporary credit given in this regard.
I have separately arranged to block my card and have asked for a replacement card to avoid further misuse.
_____________________
______________________
_______________________
Phone Numbers: Office:
(Residence):
(Mobile):
________________________________________________________
___________________________________
Address:
E-mail:
__________________________________
_____________________________________
Disputing Cardholder’s Signature:
Date:
………………………………………………………………………………………………………………………………
(FOR BANK USE ONLY)
Received by (Staff Name): _________________ Date/Time: _________________ Case Reference: ______________

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