Cardholder Dispute Form printable pdf download

Cardholder Dispute Form

FAX#

FAX#: 770-396-0777

EMAIL:

ETURN TO MEMBER

SERVICESU

RETR

TO MER SERICES

Credit/Debit Account # _______________________________ Cardholder Name _______________________________

(16 Digit Card Number)

Cardholder Phone #_________________________

Disputed Amount $_________ Post Date ________

Merchant Name______________________________________ Disputing more than one item? Yes ___ No

____

If Yes, then this is number ___ of ___ (e.g. 1 of 3) ONLY ONE TRANSACTION PER FORM

Email Address _______________________________________

SIGNATURE REQUIRED __________________________________________________________________

BEFORE DISPUTING CHARGE, YOU MUST MAKE EVERY EFFORT TO

RESOLVE THE DISPUTE WITH THE MERCHANT.

Select Type of Dispute (Check ONLY one)

Did not recognize – Please attempt to contact the merchant prior to disputing the charge.

• When did the Cardholder contact the Merchant? (mm/dd/yy) ____/____/____

• What was the outcome of the merchant contact? ___________________________________________________

I was billed twice for a single purchase – Cardholder certifies one transaction is valid, but posted more than

once. All cards issued to me are in my possession

• Valid Transaction $_____________ Post date (mm/dd/yy) ____/____/____

• Invalid Transaction $_______________ Post date (mm/dd/yy) ____/____/____

Membership Cancellation – Please enclose copy of letter, email, or fax informing the merchant of cancellation.

• When did the cardholder contact the merchant? (mm/dd/yy) ____/____/____

• Reason for cancellation? ______________________________________________________________________

• Date of cancellation (mm/dd/yy) ____/____/____ Cancellation # ______________________________________

• Were you advised of a cancellation policy? Yes ______ No ______

If Yes, what were you told? ____________________________________________________________________

Merchandise was returned - You must attempt to return the merchandise prior to exercising this right. Please

attach signed proof of return or credit slip.

• What was ordered? __________________________________________________________________________

• What was received? _________________________________________________________________________

• Reason for returning _________________________________________________________________________

• Was merchandise suitable for the purpose intended?________________________________________________

• Merchant’s response _________________________________________________________________________

EMAIL:

On The Grid Financial

Updated 09/08/15

5901A Peachtree Dunwoody Road, Ste 275 • Atlanta, GA 30328 • 770.396.9005 or

800.360.6362

Cardholder Dispute Form

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