Dispute Notification Form - Authorized Transactions
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Dispute Notification Form – Authorized Transactions
Please complete this Dispute Notification Form to initiate a dispute relating to any authorized
transactions on your card. This form must to be completed and submitted to Netspend as soon as
possible, but no later than 60 days after the date of the transaction in dispute. A decision will be
made regarding whether the funds in dispute will be credited to your card within 10 business days
after our receipt of the completed Dispute Notification Form. Supporting documentation will assist
in our determination.
Cardholder Name: ________________________
Phone Number: __________________
_____________________________________________________________________________
Address City State Zip
Card or Account Number: ____________________
Claim Number _________________
Merchant Name: ___________________________
Transaction Amount: ____________
Was the purchase merchandise or service?
Merchandise
Service
Did you receive the merchandise or service?
Yes
No
Date: ____________
(MM/DD/YY)
Was the merchandise damaged or not as described?
Yes
No
Please explain: ________________________________________________________________
_____________________________________________________________________________
Was the order cancelled?
Yes
No
Date: ____________
(MM/DD/YY)
Did you contact the merchant?
Yes
No
Date: ____________
(MM/DD/YY)
-If yes, method of contact (Circle one)
Phone
Email
In Person
Web
What did the merchant say? ______________________________________________________
_____________________________________________________________________________
Did you return the merchandise?
Yes
No
Date: ____________
(MM/DD/YY)
Did the merchant accept the return?
Yes
No
Date: ____________
(MM/DD/YY)
Will the merchant provide a refund?
Yes
No
Unsure
Amount: ____________
Was this a double charge?
Yes
No
Please provide a detailed explanation of what happened (attach additional pages if needed)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Please sign and fax to:
512-531-8770
Include a full copy of the police report and any other supporting documents, i.e. receipts, emails, shipping or tracking
information, contracts, cancellation information, when submitting this form.
___________________________ _______________
Card Holder Signature
Date
CH0006
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Parent category: Business