Fillable Debit/atm Card Dispute/fraud Package Checklist Template (Page 3 of 4) in pdf

Service not as Described (The service I received was not what I expected based on the description provided by

the merchant)

What was purchased? _____________________________________

Date the service was received: _____________________

Date you cancelled or attempted to cancel the service: __________________

Was merchandise received with the service? _______________

If yes, please provide the following:

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 service you received was

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

Credit not Processed (I did not receive credit that was promised to me by the merchant)

What was purchased? _____________________________________

Expected date of credit: _________________________________

Date merchandise or service was received: ____________________

Date merchandise or service was returned or cancelled: __________________

If credit is for merchandise, please provide the following:

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 your reasons for cancellation/return in

the space for additional information below.

Please provide a copy of the return receipt or proof of return, such as a postal receipt if applicable. Please provide

any documentation you have, such as a credit voucher, that supports your claim the merchant promised you a

credit.

Non‐Receipt of Merchandise or Service (I did not receive the merchandise or service I ordered by the agreed

upon date)

What was purchased? _____________________________________

Date you expected to receive the merchandise or service: _________________

If merchandise, was it to be shipped or picked up? _________________

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

below.

Additional Information (Please provide additional information required for the dispute type and a full description

of your interaction with the merchant from purchase to your last contact. Attach additional pages if necessary.)

_____________________________________________________________________________________________

Note: FIS has final responsibility to determine the correct reason code based on information provided and

investigation results.

Debit/atm Card Dispute/fraud Package Checklist Template Page 3