Fillable Credit Card Dispute Form printable pdf download

CREDIT CARD DISPUTE FORM

Name (First, Middle, Last)

Account Number

Member

Mailing Address

City

State

Zip Code

Information

Daytime Phone Number

Evening Phone Number

Signature

Member Signature

Date

If a transaction appears on your statement that you believe is an error, and you have been unable to resolve the situation

with the merchant, please complete and sign a copy of this form. This form must be received at the Customer Service

address of fax number stated below within 60 days of the closing date as printed on your statement. Please include a

copy of your statement highlighting the disputed transactions when mailing or faxing a copy of this form to:

CUSTOMER SERVICE

PO BOX 30495

727-570-8810

TAMPA FL 33630-3495

Transaction Amount

Transaction Date

$_________________

___________________________

Dispute Amount

Reference Number

Transaction

$_________________

___________________________

Information

Merchant Name

________________________________________________________________________________

I contacted the merchant on ______________(date) in an attempt to resolve this dispute.

I certify that the charge listed above was not made by me or a person authorized by me to use my card. In

addition, neither I, nor anyone authorized by me received the goods or services represented by this charge.

I certify that I did not participate in nor authorize the above referenced mail order or telephone order

transaction(s). I understand that no signed or imprinted sales slip copy is available for verification purposes.

Although I did participate in a transaction with the merchant, I was billed for _______ transaction(s) totaling

$____________ that I did not participate in, nor did anyone else authorized to use my card. I do have all my cards

in my possession. Enclosed is a copy of my sales slip for the valid charge.

I have not received the merchandise that was to have been shipped to me. Expected date of delivery was

___________ (mm-dd-yy). I contacted the merchant on _____________(mm-dd-yy) and the merchant’s response

was __________________________________ (In order to assist you more effectively, you must contact the merchant

and inform us of their response)

I have returned merchandise on ____________(mm-dd-yy) because

___________________________________________________________ (Please provide a copy of the return receipt, or

proof of return)

The attached credit slip was listed as a charge on my statement.

I was issued a credit slip for $____________ on _______________(mm-dd-yy), which did not appear on my statement.

A copy of my credit slip is enclosed.

Merchandise, which was shipped to me, arrived damaged and/or defective on ______________________(mm-dd-

yy). I returned it on ___________________(mm-dd-yy). Merchant’s response was

________________________________________________________________. A copy of my credit slip and/or postal

receipt is enclosed.

Credit Card Dispute Form

Related Articles

Related forms

Related Categories