WW-CARD-DISPUTE (MAR 2011)
Instructions: You should first make a good-faith effort to settle a disputed transaction(s) directly with the merchant. If assistance is
required, please complete this form, and fax or mail with required enclosures within 60 days of the transaction date to:
Mail To: WageWorks, Inc. OR Fax: (866) 672-0899
Attn: Card Operations – Dispute
P.O. Box 60068
Phoenix, AZ 85082-0068
Employee Name (Last, First)
Last 4 Digits of SSN/Employee ID
Commuter Parking Healthcare
If disputing more than three (3) transactions, please list on a separate sheet and attach.
Reason for Dispute (check only one box below)
Please attach a copy of the original signed card receipt for each disputed transaction.
I have not received the merchandise or services represented by the transaction. The expected date of delivery
of services was __________________ (date).
(Please describe your efforts to resolve this matter with the merchant, the date(s) you contacted them
and their response in the Merchant’s Response section below.)
I did not give authorization for anyone to make this transaction. Further, that no goods or services represented
by the charge were received by me or anyone I authorized.
My WageWorks Card was in my possession
My WageWorks Card was NOT in my possession (i.e. lost and/or stolen)
Defective or Wrong
Merchandise
I returned the merchandise on ___________________ (date) because it was
_________________________________________________________________________.
Charge(s) Paid by Other
Means
I already paid for the goods and/or services by means other than my WageWorks Card.
(Please provide a copy of the front and back of the Cancelled check, money order, cash receipt, credit
card statement, or other documentation as proof of purchase/payment. Describe your efforts in the
Merchant’s Response section below.)
I did not receive credit from the merchant shown above.
(Please describe your efforts to resolve this matter with the merchant, the date(s) you contacted them
and their response. Provide a detailed statement explaining your reason(s) for disputing this charge.)
Merchant Response (provide all details and dates of merchant interaction from the dispute reason above)
If additional space is needed, please provide details on a separate sheet and attach.
By Signing, You Consent to the Following:
I give my authorization to WageWorks, Inc. to release any information regarding my Card and/or Card account to any local, state and/or
federal law enforcement agency so that the information can, if necessary, be used in the investigation and/or prosecution of any person(s)
who may be responsible for fraud involving my card and/or card account.
I will cooperate in any investigation and promptly disclose any information requested by WageWorks, Inc.
I understand that incomplete or inaccurate information could result in the decline of my dispute claim.
Cardholder Signature (required): ___________________________________________________ Date: ___________________________
Employee Signature if not Cardholder (required): _____________________________________ Date: ___________________________
