Fillable Instructions for Completing a Dispute Form

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Instructions for Completing a Dispute Form

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The Instructions for Completing a Dispute Form form is 2 pages long and contains:

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  • 4 check-boxes
  • 27 other fields

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File type: PDF

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P.O. Box 3900, Springfield MO 65808
Comenity Direct Customer Care: 833-755-4354
direct.comenity.com
Instructions for Completing a Dispute Form
Each disputed transaction must meet the following criteria in order to be processed:
1. The account holder must notify Comenity Direct and complete this form within 60 Calendar Days of the
statement date on the statement the disputed transaction first appeared.
2. One form may be used for multiple transactions.
3. All sections must be completed.
For questions about filling out this form, please contact Comenity Direct at:
(8
33) 755-4354, Monday – Friday, 8am – 5:00 CT
Please submit the Dispute Form by one of the following methods:
Secure Message Login to your online banking and select “Messages” from your menu or Dashboard then
select to “Start a Conversation” select the icon next to “Type your message..." select
“Files” select the completed form type and title your message: Dispute select “Send”
Fax 801-542- 9056
Mail Comenity Direct
Attn: Comenity Direct Management
P.O. Box 3900
Springfield MO 65808
For Overnight Delivery
Comenity Direct
Attn: Comenity Direct Operations
2131 E. Primrose
Springfield, MO 65804
Dispute Form
1. I am first duly sworn and state I am:
Name
Account
Mailing Address
City, State, Zip Code
Phone Number Home Work
Email Address
2. The disputed transaction(s) is/are a: (check all that apply)
☐ Check
☐ Wire
☐ ACH (Electronic Funds Transfer)
☐ Other (please describe)
3. Transaction Details:
Date
Description
Amount
(If m
ore space is required, use a separate sh
eet)
4. Description of dispute
5. I understand this dispute may be subject to investigation by local, state, and/or federal law enforcement agencies. I
may be required to comply with a court order or subpoena to give testimony.
6. I understand making a false sworn statement is subject to federal and/or state statutes and may be punishable by
fines and/or by imprisonment.
Signature: Date:
FOR COMENITY DIRECT OPERATIONS USE ONLY
Received By: Received Date:
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Instructions for Completing a Dispute Form

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Completed 18 August 2021

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