Cardholder Dispute Form (Page 2 of 2) in pdf

Cardholder Dispute Form

RETURN TO MEMBER SERVICES

FAX#: 770-396-0777

EMAIL:

I did not receive the merchandise - Please contact the merchant and notify us of the outcome.

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

• What was the outcome of the merchant contact?___________________________________________________

• What was the expected delivery date? (mm/dd/yy) ____/____/____ Pickup date? (mm/dd/yy) ____/____/____

• Did the Cardholder cancel with the merchant? No ____ Yes ____

If yes, when? ____/____/____ How? _____________________________________________________________

• What was the merchandise that was ordered? _____________________________________________________

I was overcharged for the purchase - Please include a copy of the signed sales receipt.

My credit posted as a sale - Please attach a copy of the credit slip and the original sales slip.

The credit did not post to my account - Please enclose a copy of the dated credit slip or notice of credit from the

merchant and a detailed explanation of your dispute.

I paid by other means - You must provide proof of paid by other means such as a copy of

the cancelled check (front and back), a cash receipt, or a billing statement from another credit

card .

• When did the Cardholder contact the merchant? ____/____/____

• What was the outcome of the merchant contact? ________________________________

________________________________________________________________________

I was charged for a hotel room, which I cancelled - Cancellation number is required.

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

• If Yes, what was the policy? ________________________________________________

• Cancellation number __________________(REQUIRED) Cancel date ____/____/____

• Copy of phone bill showing you contacted the merchant to cancel.

Service Dispute - Please describe the nature of your dispute and your attempts at resolution

on a separate sheet of paper and attach to this form. Include copies of second opinions

from a certified merchant on their invoice or letterhead, repair bills, contracts or other

supporting documentation.

Other - Please enclose a DETAILED description on a SEPARATE SHEET and attach it to

this form.

(credit union use only)

Date form received: ____/____/____

Provisional credit amount: ___________

Processing teller #: __________

Date applied: ____/_____/_____

RETURN TO MEMBER SERVICES

EMAIL:

FAX#: 770-396-0777

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 Page 2