Cardholder Dispute Form/debit Card Dispute Statement Form Page 2
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4I did not receive the merchandise - Please contact the merchant and notify us of the outcome.
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When did the Cardholder contact the merchant? ____/____/____
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What was the outcome of the merchant contact? _________________________________
________________________________________________________________________
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What was the expected delivery date? ____/____/____ Pickup date? ____/____/____
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Did the Cardholder cancel with the merchant? No ____ Yes ____
If yes, when?
____/____/____ How? _________________________________________
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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 .
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When did the Cardholder contact the merchant? ____/____/____
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What was the outcome of the merchant contact? ________________________________
________________________________________________________________________
I was charged for a hotel room, which I cancelled - Cancellation number is required.
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Were you advised of a cancellation policy? No _____ Yes _____
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If Yes, what was the policy? ________________________________________________
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Cancellation number __________________(REQUIRED) Cancel date ____/____/____
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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.
I did not authorize this charge - I certify that I did not authorize or participate in this
transaction with the above-mentioned merchant, nor did I authorize anyone else to use my
card. To use this option, you must report your card lost or stolen. If you have not, please call
1-800-449-7728 before sending in this form
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If this was for a hotel room, did you request a reservation? No ____ Yes _____
If Yes, this is not an unauthorized charge. You must call the merchant and attempt to resolve the
dispute. If you received a cancellation number for a reservation, please see the dispute reasons listed
above.
MEMBER MUST ALSO COMPLETE A DETAILED DESCRIPTION (STATEMENT) ON A SEPARATE
SHEET AND ATTACH IT TO THIS FORM. (SEE FOLLOWING PAGE)
DSP Cardholder Dispute Form/OPS352
Revised 3/24/04
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