Statement of Disputed Item
Instructions: Your company should first make good-faith efforts to settle a claim or dispute for purchases directly with the merchant. If assistance
from Bank of America is required, please complete this form, and mail or fax with required enclosures within 60 days from
P.O. Box 53142
Phoenix, AZ 85072-3142
Phone (800) 352-4027 Fax (888) 678-6046
Gov't/Agency Name: __________________________________________________________________________
This charge appeared on my statement:
Billing close date:
Merchant Location: ___________________________________________________________________________
****Please check only ONE of the following****
I did not authorize, nor did I authorize anyone else to engage in this transaction. No goods or services represents by the above charge
were received by me or anyone I authorized. The card was in my possession at the time of the transaction.
Charge Amount Does Not Agree With Order Authorizing The Charge
The amount entered on the sales slip was changed from $_______ to $_______. I have enclosed a copy of the unaltered sales slip.
Merchandise or Services Not Received
I have not received the merchandise or services represented by the above transaction. The expected date of delivery or services was
___________. (On your business letterhead, please describe your attempt to resolve this matter with the merchant, the date(s)
I did engage in the above transaction, which I am now disputing. I have contacted the merchant, but I have been unable to return the
merchandise and/or I have been unsuccessful in reaching an acceptable resolution with them. (On your business letterhead)
Defective or Wrong Merchandise
I returned the merchandise on (date) __________________ because it was:(please choose one):
__defective __wrong size __wrong color __wrong quantity
Recurring Charges After Cancellation
On _________ (date), I notified the above merchant to cancel our monthly/yearly agreement. Since then, my account has been charged
______ time(s). (Please enclose a copy of the merchant’s response to confirmation of your confirmation of your cancellation).
Items Charged Already Paid by Other Means
I already paid for the goods and/or services represented by the above charge by means other than my card. (We must have a copy of the
front and back of the canceled check, money order, cash receipt, credit card statement, or other documentation as proof of payment.
Credit Appears as a Charge
The enclosed Credit Voucher appeared as a charge on my card account.
Credit From Merchant Not Received
I did not receive credit for the enclosed Credit Voucher within 30 calendar days from the date it was issued to me by the merchant
Hotel Reservation Canceled
I did make a reservation with the above hotel which I then canceled on __________ (date) at _________ (time). At that time, I asked
for a cancellation number which is ___________________. (Please check one if applies):
Double or Multiple Charges
My account has been doubled charged. The first charge appeared on my ___________ (date) billing.
Cardholder's Name (Printed)