Transaction Dispute Form (Page 2 of 2) in pdf

⁮

DEFECTIVE MERCHANDISE

I am disputing the quality of goods/services I received from merchant. I have contacted the

merchant/retailer . The response to my request for refund, is stated on annexure attached herewith.

⁮

CREDIT NOT RECEIVED

I was given a credit slip in the amount of _____________on_________ (DD-MM-YYYY) by the merchant

retailer which has not yet appeared on my billing------- Statement (indicate month) The copy of the credit

slip is attached.

⁮

PAID BY OTHER MEANS

I paid for the transaction by

⁮Cash

⁮Cheque

⁮Draft

⁮Other credit card. I attach

⁮cash receipt

or⁮ copy of cheque / Cheque no. alongwith Bank statement

or⁮other credit card

statement.

⁮

MERCHANDISE RETURNED

I have returned the merchandise and requested a refund from the Merchant retailer and have forwarded a

copy of the proof of return to him. I attach proof of return herewith.

⁮

NOT AS DESCRIBED

The goods/services are different from what was ordered or described. On attached sheet I have explained

what was expected, what was received, and indicated my attempt to return the goods. The proof of return

is also attached.

⁮

GOODS / SERVICES NOT RECEIVED

I have not received the goods/services and for that reason,I contacted the Merchant/retailer

on___________(DD-MM-YYYY) . The merchant response to my request for a refund or delivery date is

given on separate attached sheet .The copy of letter to the merchant attempting to resolve the dispute is

enclosed.

⁮

ATM DISCREPANCY

The amount on my ATM slip differs from the amount billed in statement. Attached is my

receipt showing the correct amount. The difference in amount is ______________ or I

did not receive cash from ATM.

ANY OTHER

(Give full details)

Primary Cardholder Signature: _________________________________

Add-on cardholder Signature: ____________________________(mandatory if the

transactions disputed are done through the Add on Card)

IMPORTANT NOTE

•

Cardholder is requested to submit card statement highlighting disputed transaction and

required documents wherever it is requested

•

After dispute charges are resolved, should such charges recur in the statement, you are

requested to intimate the Bank for these disputed charges vide this form within 30 days of

statement date to enable us to take up the dispute with the member banks. After the lapse of

30 days, it will be construed that all the charges are acceptable and in order.

•

A retrieval fee as prescribed in schedule of charges will be levied on per transaction basis to

your account

Transaction Dispute Form Page 2

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