Fillable File a Dispute by Mail (Capital One)

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File a Dispute by Mail (Capital One)

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The File a Dispute by Mail (Capital One) form is 2 pages long and contains:

  • 1 signature
  • 10 check-boxes
  • 45 other fields

Country of origin: US
File type: PDF

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File a Dispute by Mail
We advise you to attempt to resolve with the merchant, as that is usually the fastest way to resolve a dispute. If you want
to le a dispute with Capital One, please complete and sign this form with your detailed information. Provide copies of all
documentation that will help us investigate your dispute (contracts, invoices, detailed letter, cancellation number, etc.) Do
not mail your dispute form or letter with your credit card account payment.
Merchant Name:
Your Name and/or Business’ Name:
Last 4 Digits of Your Card:
/ /
Transaction Amount:
$
Disputed Amount:
$
(if less than transaction amount)
Transaction Post Date:
Please tell us why the item noted is in error. Only check one box that ts the description.
I certify that the charge in question was a single transaction, but was posted twice to my statement. I did not authorize
the second transaction.
Transaction Post Date:
/ /
Sale # 1:
$
Transaction Post Date:
/ /
Sale # 2:
$
I have not received the merchandise/service that was to be provided to me by the expected date of _____/_____/____
(date) .
Optional: I have asked the merchant on ____/_____/____ (date) to credit my account. If available, provide
confirmation #: ____________.
Merchandise that was shipped has arrived damaged and/or defective or not as described. Optional: I returned it on
_____/_____/____ (date) and asked the merchant to credit my account. Enclosed is my return receipt copy or tracking
number for this return.
Please provide a description of how the merchandise received was damaged and/or defective or not as described:
I notied the merchant on _____/_____/____ (date) to cancel the pre-authorized monthly billing but am still being
charged. The reason for my cancellation is: __________________________________________________________________.
Page 1 of 2
Page 2 of 2
I was charged for services or accommodations which I cancelled on _____/_____/____ (date). Please note cancellation
#: ___________________, or see attached communications (email/letter) or phone bill showing the date and time when
I contacted the company to cancel.
The amount of the charge was increased from $__________________ to $_______________ or my sales slip was added
incorrectly. Enclosed is my copy of the sales receipt that shows the correct amount.
Although I did engage in a transaction with the merchant, I was billed for ________ transaction(s) totaling
$_____________ that I did not engage in, nor did anyone else authorized to use my card. I or my authorized users
have all cards in our possession. Enclosed is a copy of my sales receipt with the valid charge.
My card was used to secure a purchase but payment was made by other means. (Attach copies of the cancelled check
(front and back), cash receipt or other credit card account statements showing the transaction)
I believe Capital One has billed me in error. Enclosed is my copy of the sales receipt that shows the correct amount.
Other — Please explain
Other Telephone:
Signature:
Home Telephone:
Date:
/ /
Please return the dispute form to the address below and keep a copy of this form for your records.
Capital One Disputes, P.O. Box 30279, Salt Lake City, UT 84130-0279
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File a Dispute by Mail (Capital One)

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Completed 5 October 2020

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