Merchant Employee

Today’s date

Requested by:

ACCOUNT INFORMATION

Company Name:

Account Number/Carrier ID:

Card Number(s):

Cardholder Name:

Transaction Date(s):

Transaction Count:

Total Amount of Dispute:

/ / through / /

$

Company email:

Company Fax Number

REQUIRED: The merchant was contacted on: / /

Note: Details of the attempt to resolve with the merchant must be noted under the “additional detail” section below, under Dispute Details.

Please attach any supporting documentation with your dispute (Police Report, Tansaction Detail Report, etc.) and provide all relevant details as to why the transactions are being disputed for expedient processing. Incomplete forms may be returned.

While the claim is being processed, please review the following recommendations:

Your Company is obligated to keep the account current. If the account is due any credit, it will be granted at the resolution of the claim.

We recommend your Company file a police report and if applicable contact the merchant location(s) immediately for possible video surveillance evidence as most such locations keep surveillance tape for only a short period.

Resolution to a claim may take, on average, 60–90 days to complete and resolution may be communicated to the company by letter or email. Company is responsible for payment of the total balance until resolution has been communicated.

If your account currently does not have Authorization Controls assigned to the cards, we strongly encourage establishing these controls. If assistance is needed with adding these controls, please contact Customer Service or Account Management directly.

If additional information is needed, we will contact you.

Signature:

To the extent that this form is not signed by Company’s representative, by submitting a copy of this document to a third party, the issuer certifies (1) the relationship between itself and the cardholder, and (2) that this form is a true, accurate and complete (unedited) message the issuer received from the cardholder.

Please fax/email completed form to:

952-***-**** or ****************@******.***

Reference your Account Number/Carrier ID in e-mail subject line

Incomplete Forms May Be Delayed or Not Processed

DISPUTE DETAILS

Please indicate which EFS product is involved in the dispute:

MasterCard® Fleet/Fuel Card (Non-MasterCard®) Money Code

Plastic

Virtual Card

Are payroll funds subject in the dispute?

Yes No

Select the Following Option(s) That Best Describes the Situation:

The merchant charged a different amount than agreed.

The amount authorized by the cardholder was $ . The amount charged by the merchant is: $

When the merchant was contacted, the merchant refused to:

Adjust the Price; Repair or Replace the Goods (or other things or value); Issue a Credit

Note: if none of the above is applicable, describe the merchant’s response in the “additional detail” section below.

The goods or services did not conform to the merchant’s description for the transaction (i.e. different quantity, quality, etc.). When the merchant was contacted, the merchant refused to:

Adjust the Price; Repair or Replace the Goods (or other things or value); Issue a Credit

Note: if none of the above is applicable, describe the merchant’s response in the “additional detail” section below.

Only one sale was authorized for $ (Please select one of the following)

This transaction is a duplicate for the same amount charged on: / / (OR)

An additional charge of $ was processed without authorization.

All cards are in the possession of the authorized cardholder.

A restricted product was purchased at this merchant.

Note: proof must be submitted, i.e. a ticket or invoice copy.

On: / / the merchant agreed to refund: $, and the merchant has not refunded that amount.

Note: proof must be submitted, i.e. a copy of a receipt showing intended refund.

Payment was made to the merchant by other means, and the merchant also charged Customer’s EFS account. When the merchant was contacted, the merchant refused to:

Adjust the Price or Issue a Credit

Note: proof must be submitted, i.e. if paid by check, provide a copy of the canceled check front & back.

Other—Please provide your reason for dispute in the area provided below for additional detail.

The card(s) is in the possession of the Company/cardholder and the card was not used for the suspicious/unauthorized transaction(s)

OR indicate the card is: Lost

Stolen

The intentional improper/unauthorized use:

Former Employee (If Former Employee, please specify exact dates of employment: from / / to / / )

Current Employee

Another Suspect (Please Identify: Relationship: )

Unknown Party

Suspect a merchant employee and a company employee is perpetrating intentional misuse or abuse of card.

Suspect the merchant is conducting the sales without the card present.

Other (please explain):

Please fax/email completed form to:

952-***-**** or ****************@******.***

Reference your Account Number/Carrier ID in e-mail subject line

Incomplete Forms May Be Delayed or Not Processed

Contact this candidate