Fillable Citibank Commercial Cards Cardholder Dispute Form

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Citibank Commercial Cards Cardholder Dispute Form

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Citi Transaction Services
transactionservices.citi.com
© 2012 Citibank, N.A. All rights reserved. Citi and Arc Design and Citibank are registered service marks of Citigroup Inc.
1043972 12/12 1 of 4 9213
Citibank
®
Commercial Cards
Cardholder Dispute Form
APC/PA’s Name: Date:
Cardholder’s Name: Merchant Name:
Account Number: — — — —
Transaction Date: Reference Number:
Transaction Amount: Posting Date: Dispute Amount:
Daytime Phone: Fax Number: E-mail Address:
Cardholder/PA/APC’s Signature:
FAX TO:
Toll Free Fax: 866-763-7946 Direct Fax: 605-357-2019 MAIL TO:CitibankCorporateCardServices•POBox6125
SiouxFalls,SD57117-6125
Please select one dispute reason from the list below and completely answer all questions. Please complete and sign, then
forward to Citibank
®
and the Program Administrator/Agency Official (as determined by your internal procedures), within 60
days of the statement date on which the disputed transaction posted so that we may investigate.
□ Copy Request
I am requesting a copy of the sales draft for my records. I will receive this copy within 45 calendar days. If it is not
my charge, I will need to dispute this item by contacting Citi within 60 days of the statement date.
□ Hotel
Cancellation
□ With Cancellation Number:
I guaranteed a hotel reservation for late arrival and then cancelled it on
______________ (date) at _________ (am/pm)
with cancellation number
_______________________________________________________
Was the cancellation policy given to you at the time of reservation? □ Yes □ No
If yes, please provide the details of the cancellation policy:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
□ Without Cancellation Number:
I guaranteed a hotel reservation for late arrival and then cancelled it on
_______________ (date) at _______ (am/pm)
Nocancellationnumberwasgiven.Pleaseprovidethedetailsofthecancellation,themerchant’sresponsetoyour
cancellation request and the name of person accepting the cancellation, if available:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Was the cancellation policy provided to you at the time of reservation? □ Yes □ No
If yes, please provide the details of the cancellation policy:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I understand it is required that I have attempted to contact the merchant and travel agent (if applicable), and their
response on
_____________ (date) was: _____________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please fax/mail proof of cancellation such as a copy of a phone bill showing the date and time the call was made
to cancel the reservation.
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Citi Transaction Services
transactionservices.citi.com
© 2012 Citibank, N.A. All rights reserved. Citi and Arc Design and Citibank are registered service marks of Citigroup Inc.
1043972 12/12 2 of 4 9213
□ Airline Ticket
Cancellation
Dispute
I have cancelled the above identified airline ticket on
_______________ (date) because (reason): ___________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I was billed twice and I did not travel on ticket number
______________ . When I ordered the ticket, I understood it
was fully refundable if I chose to cancel.
On________________________________________(date),Icontactedthemerchantandtravelagent(ifapplicable)
and their response was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
The name and number of the merchant and travel agent (if applicable) is:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Pleaseprovidethedetailsofthecancellationpolicyandcancellationnumber,ifreceived:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
□ Duplicate
Processing
I engaged in a transaction with the above merchant. I was billed for the same transaction more than once.
□ Multiple
I engaged in a transaction with the above merchant. I have no knowledge of the transaction noted above and it
was not authorized by me or anyone representing me. My cards were in my possession at the time of the above
transaction.
The correct transaction took place on
__________________ (date), in the amount of $ __________________.
□ Credit Not
Received
I engaged in a transaction with the above merchant. I dispute the entire charge or a portion of it in the amount
of $
__________________________ .
I have contacted the merchant and asked that a credit be applied to my account. I received a credit voucher for the
above listed charge, but it has not been applied to my account.
Please fax/mail proof of credit from the merchant. If you don’t have proof of credit, please select another
dispute type.
□ Merchandise/
Service Not
Received
Although I engaged in a transaction with the above merchant, I never received
______________________________________________________________________ (description of merchandise/service)
in the amount of $
_______________________ .
Iexpectedtoreceiveiton ______________ (date). If merchandise was to be sent, where was it to be delivered?
_____________________________________________________________________________________________ (Location).
I have contacted the merchant and asked that a credit be applied to my account. I contacted the merchant
on
_______________________(date) and their response was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Account Number:
______________________________
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Citi Transaction Services
transactionservices.citi.com
© 2012 Citibank, N.A. All rights reserved. Citi and Arc Design and Citibank are registered service marks of Citigroup Inc.
1043972 12/12 3 of 4 9213
□ Merchandise
Returned
My account has been charged for the above listed transaction, but the merchandise in the amount of
$
_____________________has since been returned on ____________________(date).
The reason for return was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I have contacted the merchant on
________________________ (date) and their response was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Pleaseprovidedetailsofthemerchant’sreturnpolicy,ifonewasprovided:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Pleaselistallitemsthatwerereturnedtothemerchant:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Pleasefax/mailproofofyourreturn/refusalofthemerchandise.Itcanbeobtainedbyrequestingatracethrough
the local office of the delivery company that shipped the merchandise for you (if returned) or to you (if refused).
If this proof is not available, please provide the following information:
Date merchandise was received:
__________________________________________________________________________
Invoice\tracking number for return: _______________________________________________________________________
Name of shipping company for return: _____________________________________________________________________
□ Merchandise/
Service Not
As Described
Theitem(s)didnotconformtowhatwasagreeduponwiththemerchant.Provideanexplanationofwhat
merchandiseorservicewasreceivedandwhatwasexpected:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Ifwrittendocumentationisavailablethatdescribeswhatwasexpectedtobereceived,pleasefax/mailacopy.
Pleasenotewherethistransactiontookplace:
□ atthemerchant’splaceofbusiness □ through the mail □ e-mail □ over the telephone
Ireceivedorexpectedtoreceivethemerchandise/serviceon _____________(date). The merchandise/service was
returned or cancelled on
_____________ (date). I contacted the merchant for a credit on ______________ (date) and
attemptedtodiscussthematter.Themerchant’sresponsewas:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Pleasesendproofofyourreturn/refusalofthemerchandise.Itcanbeobtainedbyrequestingatrace
through the local office of the delivery company that shipped the merchandise for you (if returned) or to you
(if refused). If this proof is not available, please provide:
Name of shipping company for return:
_____________________________________________________________________
Invoice tracking number for return: _______________________________________________________________________
Account Number: ______________________________
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Citi Transaction Services
transactionservices.citi.com
© 2012 Citibank, N.A. All rights reserved. Citi and Arc Design and Citibank are registered service marks of Citigroup Inc.
1043972 12/12 4 of 4 9213
□ Credit Applied
as a Charge
I have received a credit voucher for the above listed charge, but it was applied to my account as a charge.
Please fax/mail us proof of credit from the merchant.
□ Cancelled
Recurring
Transaction
(Merchandise
or Service)
□ With Cancellation Number:
I notified the merchant on
__________________ (date) to cancel pre-authorized recurring charges (i.e., insurance
premium, membership fee) and I was provided a cancellation number of:
_____________________________________ .
I will refuse delivery should the merchandise be received.
□ Without Cancellation Number:
I notified the merchant on
___________________(date) to cancel pre-authorized recurring charges (i.e., insurance
premium, membership fee). The merchant has charged me again after this cancellation date.
I contacted the merchant again on
_______________ (date), and their response was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I will refuse delivery should the merchandise be received.
□ Paid For By
Another
Means
My card number was used to secure this purchase; however, the final payment was made by check, cash, or another
credit card. I contacted the merchant on _____________________________ (date) and their response was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please fax a copy of the front and back of the check, a copy of the cash receipt or other documentation that
payment was made by other means. If paid by 3rd party, please include their documentation.
□ Altered
Amount
Although I engaged in the above transaction, the dollar amount of the sale has been altered from
$
__________________________ to $ ___________________________.
Please fax/mail a copy of your sales receipt, with the correct dollar amount.
□ Unauthorized
Transaction
I certify that the charge listed above was not made by me or a person authorized by me. I did not receive any goods
or services from this transaction nor did any person authorized by me.
□ Other
I notified the merchant on
_______________________ (date). I attempted to resolve the issue with the merchant and
their response was:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Account Number:
______________________________
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Citibank Commercial Cards Cardholder Dispute Form

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Completed 12 August 2021

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