Commercial Card Cardholder Dispute Form
Thank you for contacting us regarding a dispute on your Visa or MasterCard. Please use this form to explain the details of your
dispute. You may place additional details and multiple dispute items on the second page.
This form needs to be signed by the Cardholder only. Please mail or fax this form to:
Mail: Fifth Third Bank, Madisonville Operations Center, Mail Drop 1MOC2G, Cincinnati, OH 45263
Fax: (513) 358-7327
Cardholder Name: *
Last 8 Digits of Card Number: *
Company Name: *
Merchant Name: *
(required unless entering transaction on page 2)
Amount of Transaction: *
(required unless entering transaction on page 2)
Transaction Date: *
(required unless entering transaction on page 2)
Email Address: *
Customer Phone Number: *
Fifth Third Service Request Number:
*Disclaimer: A dispute form may be rejected if the noted required fields are not filled in completely.
Is the card in your possession? Yes No
Please choose the ONE category that best describes your dispute:
1. - I did not participate or authorize this transaction.
2. - I paid for this purchase another way, but it still posted to my statement. I have provided:
A cash receipt Copies of both sides of a canceled check
The credit/debit card statement where the valid charge appears
(Please note one of the above is required before Fifth Third can assist with your dispute.)
3. - This charge posted to my account twice, but I only authorized one purchase.
The valid charge posted on . My credit cards are still in my possession.
4. - The charge posted to my account for an amount different from the amount on my receipt.
I have provided a copy of my receipt showing the difference.
5. - I have not received expected goods or services. The expected date of delivery was .
I have contacted the merchant and the response was .
(Please specify the expected goods or services on the second page.)
6. - The merchandise received was not as described, poor quality, damaged, or unsuitable for the purpose intended.
I returned (or attempted to return) the merchandise on . I have contacted the merchant and their
response to the return was .
Need a second opinion on merchandise received for quality issues.
(Please provide details of what was wrong with the merchandise on the second page of the form, and include proof that the
goods were returned to the merchant, such as a tracking number.)
7. - I have returned merchandise to the merchant. A copy of my credit slip is enclosed.
8. - I have returned (or attempted to return) merchandise to the merchant. I did not receive a credit slip because
. I was informed of the merchant’s return policy, and their response to the
return was .
9. - I cancelled the transaction with the merchant on . I was informed of the
merchant’s cancellation policy, I have contacted the merchant and the response to the cancellation was
(Please include any contracts or correspondence to and from the merchant.)
10. - I cancelled the hotel reservation on . My cancellation number is .
(If no cancellation number was provided, please provide a telephone statement showing the cancellation call to the
11. - I do not recognize this transaction.
Cardholder Signature __________________________________ Date
click to sign
click to edit
Please provide a detailed explanation of the above dispute.
For multiple transactions, please fill out the following items.
Transaction Date
Merchant Name
Amount of Transaction
Dispute Reason
(category number from page one - # 1 11)
Fifth Third Use Liability Policy: If you believe that a transaction on your Account was unauthorized, you must notify us as soon as
possible but not more than sixty (60) days after the transaction in question appears on your Account Statement. You will be
required to provide us with reasonable information about the transaction to enable us to investigate the matter, and to reasonably
cooperate with us in any investigation. If you do that, and the following conditions are met, you will not be responsible for the
unauthorized transaction: (a) the transaction was not effected by a current or former employee or other Cardholder designated by you;
(b) there are no past due obligations on the Account; and, (c) you have exercised reasonable care in safeguarding your Cards and
Account from unauthorized use including that you did not provide, directly, by implication or otherwise, the right to use a Card or the
Account to the person effecting the transaction, or receive any tangible benefit from the transaction. If the conditions in this paragraph
are satisfied, we will credit your Account for the amount of the transaction in question and any fees and interest that may have been
applied or accrued as a result of that transaction. In addition, the Card Association may offer a liability protection program for small
business (as defined by them), to which unauthorized use of the Card may be subject; contact the Card Association for additional
information. We will provide a copy of the Card Association’s program literature upon request. If we have issued fewer than ten
Cards in connection with the Account, your liability for transactions by a person who does not have actual, implied or apparent
authority to use the Card or Account and whose use does not result in a direct or indirect benefit to you will not exceed $50 (or lesser
amount of the transaction) on each Card.