Transaction Dispute Form
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1
2TRANSACTION DISPUTE FORM
Date: ______________
Credit Card No: ______________________________
Telephone/ Mobile No: _________________
Cardholder Name:____________________________
Email Id: ____________________________
Add On Credit Card No. : __________________________
Add-on Cardholder Name: __________________________
Details of Disputed Transactions:
S.No
Statement
Transaction
Merchant Name
Transaction
Disputed
date
Date
Amount
Amount.
.
(INR)
(INR)
Name of Merchant Country___________
Acquirer Reference NO.______________
I am disputing the above listed transaction(s) for the reason (ticked) and mentioned below:-
UNAUTHORIZED TRANSACTION
I neither made nor authorized above transaction.
LOST/SUSPECTED FRAUD
My card was (circle one of the following choices below)
A. Lost/Stolen: on Date: __________ Location: _____________
B. Card Never Received
C. Card was in my possession at the time of fraudulent use
MULTIPLE PROCESSING
I have been charged ----- times for the same transaction. I authorized only one transaction on------
(mention the date). The original amount appeared on my------ (indicate month) statement (enclose
copy of statement)
DIFFERENCE IN AMOUNT
The amount on my sales slip differs from the amount billed and shown in------ statement(indicate
month) . I am attaching my receipt showing the correct amount. The difference in amount
is____________
CANCELLED TRANSACTION
I cancelled this transaction on ____________(indicate date).I am attaching receipt indicating the
specific reason for the cancellation and cancellation reference numbers.
Cont….
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Parent category: Financial