Debit/atm Card Disputed Transaction Form printable pdf download

Debit/atm Card Disputed Transaction Form

Debit/ATM Card Disputed Transaction Form

MasterCard rules require the cardholder to attempt to resolve any issues directly with the merchant for all

types of disputes excluding ATM withdrawal disputes, prior to disputing the transaction with their

financial institution. Prior to completion of this form you must have attempted to contact the merchant

directly.

Member Name (please print):

Member Address:

Member Phone Number:

Debit/ATM Card Number:

Member Account Number:

I have examined my account and I am disputing the following Debit/ATM card transaction(s). Attach additional

sheets, if necessary, to list all disputed transactions:

Merchant Name

Transaction Amount

Transaction Date

Total Amount of Disputed

Transactions

Merchant contact information below is required for all disputes except ATM transactions.

Date Merchant Contacted

Contact Method:

Telephone

In-Person

Other (describe)________________________________

Merchant’s Response:

Revised 5/5/2014

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Debit/atm Card Disputed Transaction Form