Merchant Officer
Resume:
CUSTOMER STATEMENT OF DISPUTED TRANSACTION
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Please complete only ONE of the sections below. Use a separate form or additional pages to document each dispute. Once completed, please send this form and any supporting documentation to assist in the investigation to the following: Fax to:
Email to:
******@*****.***
If you have any questions, please contact *******@*****.*** or 1-844-***-****. Your Name: Account #: Amount: $ Transaction Date: Post Date: Reference Number (if available): Transaction Description: Please complete only ONE of the sections below.
SECTION 1: TRANSACTION NOT AUTHORIZED
I certify that the charge(s) listed above was (were) not made by me nor a person authorized by me to use my card. I did not receive any goods or services from this transaction nor did any person authorized by me. 1. My card was (Select one):
IN MY POSSESSION NOT RECEIVED LOST STOLEN
(If applicable) What day was your card lost or stolen? 2. Do you know who made these transactions? (Select one):
NO YES (If Yes, complete the following)
Who do you think made or authorized these transactions? What is your relationship to this person? 3. Have you given permission to anyone to use your card? (Select one):
NO YES (If Yes, complete the following)
Name: Relationship: 4. When was the last time you used your card?
Date/Time: Amount: $ Merchant Name or ATM Location: 5. Where do you normally store your card? 6. Where do you normally store your PIN? 7. Please list other items that were lost or stolen, including your mobile phone or any additional cards (if applicable): 8. Have you filed a police report? (Select one)
NO YES (If Yes, complete the following)
District/Officer name: Report number: Suspect name: CUSTOMER STATEMENT OF DISPUTED TRANSACTION
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SECTION 2: ATM – CASH NOT RECEIVED
I requested $ from the ATM however I received $ . I am disputing the amount of $ as this amount was not received.
SECTION 3: INCORRECT TRANSACTION AMOUNT
The dollar amount of the transaction was increased from $ to $ . I am enclosing a copy of my debit card sales receipt, which reflects the correct dollar amount.
SECTION 4: CANCELLED TRANSACTION
I dispute the entire charge or a portion of it in the amount of $ . I contacted the merchant on (date), but no credit has been applied to my account. I received the following confirmation number when I cancelled the service: .
SECTION 5: RETURNED OR DEFECTIVE MERCHANDISE
All or part of the shipped or delivered merchandise was defective or damaged when I received it. I returned the merchandise on (date), but I have not yet received a credit. The tracking number for this shipment is: . I contacted the merchant on (date) and received the following response: . I am enclosing a detailed statement describing the defects of the merchandise and am enclosing a copy of my proof of return list of the merchandise received, the items returned, and the cost of each item.
SECTION 6: DUPLICATE TRANSACTION
The above transaction is a duplicate of an authorized transaction that took place on (date). The reference number for the authorized transaction is: .
SECTION 7: PAID FOR GOODS BY OTHER MEANS
I made the above transaction, but paid for it by (list form of payment used: cash, another debit or credit card, etc). I am enclosing a copy of the receipt showing the correct form of payment.
SECTION 8: NON-RECEIPT OF GOODS OR SERVICES
I have never received the merchandise. I expected to receive it during the week of (date). I contacted the merchant on (date), and received the following response: .
SECTION 9: OTHER (not classified above)
Please describe the situation and provide any information that would be helpful to the investigation: Cardholder signature: Date: Contact number (during the hours of 8am-5pm CST):
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