Main Content Cardholder Disputed Item Statement Name: * Street Address: * City, State, Zip: * Email: * Home Phone: * Work Phone: Card Number * Is this an EMV chip card? * Yes No Type of Loss: * Lost Stolen Card was in my possession at the time the transaction(s) occurred. Transaction Details: 1. Merchant Name: Amount: Transaction Date: 2. Merchant Name: Amount: Transaction Date: 3. Merchant Name: Amount: Transaction Date: I have examined the charge(s) on my account and question the above transaction(s): (If necessary, enter more charges.) The following explains my dispute: * I received a price adjustment (credit slip) on the above transaction and it has not appeared on my statement. I have included a photocopy of the credit slip. I certify that only one transaction was made with the above referenced merchant. On my statement, the same merchant has processed a second charge to my account, which I neither participated in nor authorized. I certify that I participated in the above transaction, but have not received the merchandise. (Describe in detail the merchandise or services you expected to receive, the expected date of delivery, and any attempts to resolve the matter with the merchant on the additional space provided) I certify that I participated in the above transaction, but have returned the merchandise/cancelled services per the merchant’s instructions and have not received credit. (Merchant cancellation policies may apply; please provide full details on the additional space provided.) I contacted the merchant and canceled the monthly recurring transaction. (Merchant cancellation policies may apply; please provide full details on the additional space provided.) I contacted the merchant and canceled my reservation. (Please provide full details on the additional space provided below including your cancellation number if you received one.) The shipped merchandise I received is defective. (Describe in the additional space the defect or damage and attempts to return the merchandise, and the merchant’s response.) The merchandise/services were not as described. (If purchase was made over the phone please indicate what was not as described. Otherwise, please provide written documentation as to what was not as described. i.e.: color, quantity, etc.) I want a copy of the sales draft (please provide reason for request in space provided below). I certify that the charge(s) was (were) not made by me or by a person authorized by me to use my card, nor were the goods or services represented by the above transaction received by myself or by a person authorized by me. (Your card will be blocked.) Dispute Details: Enter additional dispute details here. In dispute cases except those related to lost/stolen/counterfeit cards, you may be required to make an attempt to resolve the dispute with the merchant prior to filing a dispute. Please describe your attempt to resolve in the following sections: I have made an attempt to resolve with the merchant. * - Select -YesNo Date of contact: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 Contact Method: - None -TelephoneE-mailIn-personOther Merchant's Response: If no attempt, why not? Additional Comments: Leave this field blank CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.