Dispute Acknowledgement Form

Do not use this form to report disputes if your card has been lost or stolen. If it has been lost or stolen, please call us immediately at the Customer Service number located on your billing statement.

Instructions:

Step 1: Complete the information below and sign this form. Step 2: Make a copy for your records.

Step 3: Attach any other information requested below or you feel will help us resolve this issue. Step 4: Fax or Mail this form to the address listed below. Primary Cardholder Name: Primary Cardholder Address: Credit Card Client: Account Number Ends in (last 4 digits):

I am disputing the transaction for the following reason (Please check one box): I did not make the sale nor did anyone authorized to use my account make the sale. In addition, neither I nor anyone authorized to use my account received the goods or services represented by the transaction.

The goods or services were not received on expected receipt dates of / / The date I notified the merchant was / / and their response was: I cancelled my service/subscription with this merchant on / / by

(phone/mail) or but the charges still appear on my statement. Enclose any documentation.

The goods or services were received and were defective or damaged, and I returned it/contacted the store. The date in which I returned it was / /, the amount of the credit to be applied to my account was $ . Please attach a copy of the return or credit receipts received and if returned via mail, please provide proof of return.

Other Reason not listed above: (Credit not posted, duplicate sale) Please provide any additional information Please complete information regarding the disputed transaction. Date of Disputed Transaction:

Amount Disputed: $

Store/Merchant Name:

Your Daytime Phone Number: By signing below, I acknowledge that the information provided is accurate and authorize you to initiate a dispute.

Cardholder Signature: Today’s Date:

Complete this form and fax to 866-***-**** or mail to PO Box 965035 Orlando, FL 32896-5035

Our next step is to conduct our investigation. As part of this process, we need this form completed regarding the specific sale amounts, dates of the disputed item(s) and/or date returned. Once we receive this completed form we will conduct the investigation and will provide you with a response as soon as possible, but no later than two full billing cycles from the date of your inquiry. Please be assured that while we investigate your billing dispute, we will not assess interest charges and you are not required to make payments on the disputed amount. However, you are still required to make payments on the undisputed portion of your account balance.

Upon completion of our investigation, if we find a billing error(s) has been made, we will make all required adjustments to your account and the adjustments will be shown on your statement. If we find that the charge you are disputing was valid, we will notify you in writing explaining the reason(s) why and the disputed amount will be placed back on your account.

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