Form Rj5874 - Customer Statement Of Dispute Form
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Customer Statement of Dispute
Date________________________
Note: Failure to provide adequate information may affect your dispute rights and processing time. Depending on the documentation
required a dispute may take up to 60 days to process. Please be as complete and specific as possible.
Please use only one form for each charge disputed. (You may make copies of this form)
NAME__________________________________________ ________
ACCOUNT #______________________________________________
SIGNATURE_____________________________________________
EMAIL ADDRESS_________________________________________
REQUIRED
DATE OF CHARGE_______________________________________
MERCHANT NAME_______________________________________
AMOUNT OF CHARGE____________________________________
AMOUNT DISPUTED______________________________________
PHONE # (TO BE REACHED AT BETWEEN 7 AM AND 5:30 PM CT)___________________________________________________________
Please check and complete the information for the category that best applies. Additional information can be noted on the back of this form.
Cancellation/Returns—I have returned the merchandise or cancelled merchandise or services and have not received credit
What was purchased? (Please be specific)____________________________________________________________________________________
Were you advised of Merchant’s cancellation or refund policy at the time of purchase? ___Yes* ___No *Please explain policy on back of this form.
Date of cancellation___________________________________
Who you spoke with ______________________________________________
Cancellation#________________________________________
Reason for cancellation_____________________________________________
Date Returned_______________________________________
Shipping Company & shipping/tracking #______________________________
Date attempted to resolve with merchant__________________
Who you spoke with _______________________________________________
Merchant’s response______________________________________________________________________________________________________
Quality of Merchandise/Services--*
Describe the difference between what was ordered and what was received. What was defective or why the purchase is
unsuitable for your needs? YOU MAY BE CONTACTED FOR ADDITONAL INFORMATION (please use additional space on back of this form if needed)
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Date of cancellation___________________________________
Who you spoke with______________________________________________
Cancellation#________________________________________
Reason for cancellation____________________________________________
Date Returned_______________________________________
Shipping Company & shipping/tracking #_____________________________
Date attempted to resolve with merchant__________________
Who you spoke with _____________________________________________
Merchant’s response____________________________________________________________________________________________________
Non-receipt of Merchandise/Services—I did not receive the purchased services or shipped merchandise
What was purchased? (please be specific)___________________________________________
Expected date of delivery_________________
Date attempted to resolve with merchant__________________
Who you spoke with_______________________________________________
Merchant’s response_____________________________________________________________________________________________________
Transaction Errors
___I have been billed more than once for the same purchase. The original charge posted on __________________________________________
___Incorrect amount posted to my account.
Enclosed is a copy of my receipt for $_____________, but the charge posted to my account as $______________.
Unauthorized Charge *SIGNATURE ABOVE IS REQUIRED*
I did not authorize or participate in this transaction. I understand that by stating the charge is unauthorized that this account will be closed and reported
as lost or stolen upon return of this dispute form. A new account may be issued at the discretion of World’s Foremost Bank.
Charge Not Recognized
I do not recognize the transaction and require additional information to enable me to successfully identify the transaction or merchant.
I attempted to identify the charge with the merchant on (date). ___________________
WFB Visa Center * Attn: Customer Service/Disputes * PO Box 82608 * Lincoln, NE 68501-2608 Fax 402-323-4497
Revised Feb 10
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Parent category: Financial