Fillable Debit/atm Card Dispute/fraud Package Checklist Template (Page 2 of 4) in pdf

Dispute Information Form

Card #:

Cardholder Name: (please print)

First:

Last:

Please check only one statement that pertains to the dispute or fraud claim being filed and provide the information

requested. The templates below assume the cardholder’s perspective.

Unrecognized (I am not sure if I made this transaction)

Please describe your attempt to resolve this dispute with the merchant in the space for additional information

below.

Incorrect Amount (I was billed the wrong amount)

What was the amount you should have been billed? _______ (Please provide a receipt if available)

What was purchased? _____________________________________

Please describe your attempt to resolve this dispute with the merchant in the space for additional information

below.

Duplicate Charge (I have been billed more than once for the same transaction)

What was purchased? _____________________________________

Please provide a copy of the statement and identify which charge is valid and which is a duplicate.

Paid by Other Means (I paid for this transaction via another payment method or credit card)

What was purchased? _____________________________________

Paid by :( Circle One) Check Cash Another Credit Card Other __________

Please describe your attempt to resolve this dispute with the merchant in the space for additional information

below.

Please provide a copy of your cash receipt, the front and back of your cancelled check or a copy of your statement if

another credit card was used.

Cancelled (I was charged for something I previously cancelled)

What was purchased? _____________________________________

Were you advised of the merchant’s cancellation policy?___________

If so, how were you advised? ____________________________________________

What was your method of cancellation? (Circle One) Phone Mail Email Other ________

Date of cancellation: _________________

Cancellation number and/or name of person you spoke with: ____________________

Please describe your attempt to resolve this dispute with the merchant and your reasons for cancellation in the

space for additional information below.

If you cancelled by phone, please provide a copy of the telephone bill reflecting the call if available. If you cancelled

by email, please provide a copy of the email correspondence.

Merchandise not as Described (The merchandise I received was damaged, defective, or not what I ordered)

What was purchased? _____________________________________

Date the merchandise was received: _____________________

Date you returned the merchandise or made it available for pick up: ___________________

Return authorization number or cancellation number if available: _____________________

Tracking number for returned merchandise: _____________________

Please describe your attempt to resolve this dispute with the merchant and how the merchandise you received

was different from what was described in the space for additional information below.

Debit/atm Card Dispute/fraud Package Checklist Template Page 2