Cardholder Dispute Form
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2CARD ________________________________ PAGE 1 OF 2
CARDHOLDER DISPUTE FORM
Cardholder Name ______________________________________________________________________________________________________________
Card Number
______________________________________________________________________________________________________________
Transaction Date _________________Merchant Name________________________________________________________________________________
Transaction Amount $___________________________________________ Dispute Amount $__________________________________________________
_____________________________________________________________________
____________________________________________________
Cardholder Signature
Date
Please check the appropriate box below that matches your dispute type the closest. Your signature above is required.
Return this form and any supporting documents so that your dispute can be processed in a timely manner. Please answer all appropriate questions below.
The required fields per dispute type are marked with an asterisk (*). Attach a separate sheet or letter if more room is needed for your explanation. If any
of the below does not accurately reflect your dispute, please write a separate letter and include all of the transaction information listed above.
Transaction not recognized by cardholder
Cancellation dispute
Were you advised of any cancellation policy?
yes
no (if yes, explain below)__________________________________________________
______________________________________________________________________________________________________________________
* Date of cancellation:____________________________________ Spoke with: ______________________________________________________
* Cancellation number: ________________________________
* Reason for cancellation: _________________________________________________________________________________________________
I canceled this recurring transaction with the merchant on (date): _________________ how __________________________________________
* Describe your attempt to resolve with the merchant: ________________________________________________________________________
______________________________________________________________________________________________________________________
Returned merchandise dispute
* Date returned: ____________________________ Date received by merchant: ______________________
If mailed, Return Merchandise Authorization Number (RMA): __________________________
* Shipping Company: _______________________________________ Tracking number: _______________________________________________
* Reason for return: ______________________________________________________________________________________________________
If you have a credit slip or voucher or a refund acknowledgement that has not posted please provide:
* Date of credit slip: ____________________ Invoice/receipt number of the credit: ___________________________________
* Describe your attempt to resolve with the merchant: _______________________________________________________________________
______________________________________________________________________________________________________________________
I was charged two or more times for the same transaction
Date of first charge: ___________________ Date of second charge: ___________________
Date of third charge: ___________________Date of fourth charge: ____________________
* Describe your attempt to resolve with the merchant: ________________________________________________________________________
______________________________________________________________________________________________________________________
I did not receive cash from an ATM withdrawal attempt but was charged as if I did receive it
Transaction reference number: ______________________________________________
I made a single attempt and did not receive cash
I made multiple attempts and only received cash on one of those attempts
Other: _____________________________________________________________________________________________________________
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Parent category: Financial