Dispute request form

Complete this form in its entirety. We cannot process your claim until we have received all of the required information and documentation. All fields are required to be filled out, unless noted as “optional.” Please provide as much detail as possible.

1.

Upload your completed form to the Albert app by going to Albert Cash > Transactions > Tap on the transaction > Tap to report an issue, and follow the steps to upload. 2.

To process your claim, our security team will review your request form and may reach out with instructions to provide additional information if needed. 3.

Debit card and statement error disputes fall under Federal Regulation E, which states that we are allowed 10 business days to investigate a dispute claim to determine if provisional credit is warranted. If we determine there is recourse through Albert, you will receive provisional credit within 10 business days. If a provisional credit is not warranted or if all required information has not been provided, we will contact you within 10 business days. Please note that for new accounts we are allowed 20 business days to review. This Dispute request form should be completed if you have initiated a debit card transaction with a merchant and are now disputing the transaction or you have identified an error on your statement. The cardholding owner must be the person who completes this form. Instructions

Name

If lost/stolen, provide date:

If lost/stolen, provide date:

If yes, select all that apply:

Transaction amount $

Transaction date

Card number

Dispute amount $

Merchant name

Phone number Email

Card and disputed transaction information

At the time of the transaction, the card was:

Have you shared your information with others?

Lost

No Card

Stolen

Yes Phone PIN

At the time of the transaction, your phone was:

Lost Stolen In my possession

In my possession

Dispute request form

Check one category below that best describes your dispute for the transaction(s) listed above. Please include any receipts or supporting documentation with the PDF before uploading to the Albert app. Category

Canceled service (recurring transaction, i.e., subscription, membership, policy) Were you advised of any cancellation policy?

Describe your attempt to resolve with the merchant & the date(s) of contact: Date canceled with merchant:

Cancellation number:

Canceled by means of:

(if yes, explain below)

(cannot be used as attempt to resolve date)

Yes

Phone (spoke with ) E-mail

No

Item damaged or returned

Date returned:

Shipping company:

Date of credit slip:

Date received by merchant:

Tracking number:

Invoice / receipt number of the credit:

Describe your attempt to resolve with the merchant & the date(s) of contact: Reason for return:

If return was by mail, Return Merchandise Authorization Number (RMA): If you have a credit slip, voucher or a refund acknowledgement that has not posted please provide: Unauthorized / fraud

Describe your attempt to resolve with the merchant & the date(s) of contact: I didn’t authorize or engage in the transaction. (If yes, your card will be cancelled upon claim review.) Missing transfer

The merchandise arrived broken, defective or otherwise unsuitable, not as described by the merchant, and/or the item has been returned.

Type of transfer: Deposit Withdrawal

Amount of transfer $ Date of transfer:

Dispute request form

Missing refund

I was issued a credit receipt that didn’t post to my account. Describe your attempt to resolve with the merchant & the date(s) of contact: Duplicate charge

Date of first charge:

Date of third charge (optional):

Date of second charge:

Date of fourth charge (optional):

Describe your attempt to resolve with the merchant & the date(s) of contact: Describe your attempt to resolve with the merchant & the date(s) of contact: Incorrect amount

The transaction amount posted for $ but should have posted for $ Item or service not received

Merchandise or services not received. Expected delivery date: Merchant unwilling or unable to provide service.

Describe your attempt to resolve with the merchant & the date(s) of contact: Paid by other means

Check Cash Other card Other:

Describe your attempt to resolve with the merchant & the date(s) of contact: Missing refund amount $ Date merchant confirmed refund issued: Non-receipt of cash at ATM

Date of transaction

Amount received $

Amount requested $

ATM location

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