Cardholder Dispute Form/debit Card Dispute Statement Form
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CARDHOLDER DISPUTE FORM
Credit/Debit Account # ____________________ Cardholder Name _______________________
(last 6 numbers on card)
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 _____________
•
Invalid Transaction $_______________ Post date _____________
Membership Cancellation – Please enclose copy of letter, email, or fax informing the
merchant of cancellation.
•
When did the cardholder contact the merchant? _________________________________
•
Reason for cancellation? ___________________________________________________
________________________________________________________________________
•
Date of cancellation ________________
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 ______________________________________________________
DSP Cardholder Dispute Form/OPS352
Revised 3/24/04
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