Mastercard Disputed Charge Form - 2014 printable pdf download

NOTIFICATION OF DISPUTED CHARGE – MASTERCARD

Member Name: _______________________ Debit Card Number: ________________________

TRANSACTION INFORMATION

(If more than one charge is in dispute, please provide a list specifying the information below for each

charge.)

Merchant Name: ________________________ Location: _______________________________

(City, State)

Transaction Date: _______________________ Amount: _______________________________

I am disputing the transaction(s) in question because of the following reason(s):

( ) The charge(s) was paid by another means. Enclosed is a copy of the cancelled check or

cash/credit receipt.

( ) The amount signed for on the salesdraft differs from the amount billed on the monthly

statement. Attached is my copy of the sales receipt.

( ) The transaction was authorized and then canceled. A credit voucher was issued (copy

enclosed), but the credit has not posted to my account. If no credit voucher was issued,

please explain the merchant’s response to the cancellation/return.

_________________________________________________________________________

( ) I have been billed multiple times (2 or more) for the same purchase. The original charge

posted to my account on ___________________.

( ) I placed an order with the merchant above. I have not received merchandise which I

expected by ______________. I have contacted the merchant for credit but no credit has

been posted to my account.

( ) I cancelled this reservation on ___________. The cancellation number provided to me

is as follows: ____________________.

( ) I cancelled this recurring charge with the merchant on ___________. No charges after

this date are authorized from this merchant.

( ) I received merchandise different from what I ordered. Attached is a detailed letter

explaining what was expected from the merchant, what was received, and that an attempt to

return the merchandise was made.

_____________________________________

_______________________________

Member Signature

Date

_____________________________________

Telephone Number

_____________________________________________________________________________

ATTACH COPIES OF ALL RELATED DOCUMENTATION TO THIS FORM

If additional room is required to describe your dispute, please use the back of this form

Rev.2014

Mastercard Disputed Charge Form - 2014