FAX COVER SHEET
From:
Phone Number:
Fax Number:
To: MBNA Disputes
Phone Number: 1-866-601-7203
Fax Number: 1-877-839-6262
Date:
Total # of pages (including fax cover sheet):
CHECK LIST
Prior to sending in your form please ensure you have considered the following (as applicable):
IMPORTANT INFORMATION ATTACHED
Comments:
I have contacted and documented my attempt to resolve the dispute with the merchant
I have filled out the customer contact information in section 1
I have filled out the transaction information in section 2
I have filled out the critical information in section 3
I have selected only one box defining why I am disputing this transaction in section 4
I have filled out the dispute reasons information in section 5 as required based on my dispute
I have attached all additional supporting documents
I have signed and dated the form
I understand someone may follow up with me if additional information is required
TRANSACTION DISPUTE FORM
If you would like to dispute a transaction on your account statement please return this form within 60 days after the Statement Closing Date of the account statement on
which the transaction appears. Otherwise, the statement will be considered accurate (except for any amount which has been improperly credited to the account) and you may
no longer make a claim against us in respect to any item on the statement. Complete (electronically and print or print and clearly write using blue/black ink), sign a copy of this
form, and fax to 1-877-839-6262 or mail to MBNA P.O. Box 9614, Ottawa, ON K1G 6E6. If you do not have access to a printer you may write a detailed letter on a separate
sheet of paper containing the information set out below and return it to MBNA as noted above. You must use a separate form for each disputed transaction. Please do not
send your payment with your form. If you have any questions or concerns please call the MBNA Disputes department at 1-866-601-7203 between the hours of 8AM and
7PM E.T., Monday to Friday. It is mandatory that you contact the merchant in an attempt to resolve your dispute prior to contacting us.
CUSTOMER INFORMATION (Mandatory)
First/Last Name: Best Contact Telephone Number:
Today’s Date: Signature:
TRANSACTION INFORMATION (AS SHOWN ON STATEMENT) (Mandatory)
Account Number
(Last 4 digits):
Transaction Reference
Number:
Merchant Name: Amount $: Posting Date:
CRITICAL INFORMATION FOR ALL DISPUTES WITH A MERCHANT (Mandatory)
It is mandatory that you contact the merchant to attempt to resolve your dispute prior to contacting us. Please outline the details of your attempt to resolve including dates and
the merchant’s response. Please attach any written communication between you and the merchant. If additional space is required to document the details of your claim please
attach a separate piece of paper with the relevant details for each claim.
Date of attempt
to resolve:
Details of attempt
to resolve:
Merchandise or service purchased?
How did you make this purchase? (select one) Over the Phone Face to Face Online Other:
Item was received on: Contacted the merchant to cancel on:
Details of cancellation (method and merchant response):
Where are the
goods now?
(select one)
In my possession. The merchant has been notified that the goods
remain available for pick up at the merchant’s expense.
I notified them on:
In the merchant’s possession. (Please attach tracking information.)
In the possession of a government agency.☐
I have discarded the goods.
Other/Additional Information:
WHY ARE YOU DISPUTING THIS TRANSACTION? (Please select one box only)
The merchant has changed our agreement without my knowledge or consent.
(This dispute requires additional information. Please fill out all that applies in
section 5 box 1.)
The merchant is billing me on a regular basis even though I cancelled this
service. (This dispute requires additional information. Please fill out all that applies
in section 5 box 2.)
The merchant has provided me with goods/services that do not conform to
their original description. (This dispute requires additional information. Please fill
out all that applies in section 5 box 3.)
I have not received the goods/services that I ordered. The estimated delivery
date is:
The amount of this transaction was increased from the initial agreement.
(This dispute requires additional information. Please fill out all that applies in
section 5 box 4.)
I have an issue with a Hotel/ Stay or Reservation /Auto Rental.
(This dispute requires additional information. Please fill out all that applies in
section 5 box 5.)
I have not received my credit.
(This dispute requires additional information. Please fill out all that applies in
section 5 box 6.)
This transaction failed to complete but billed regardless.
(This dispute requires additional information. Please fill out all that applies in
section 5 box 7.)
I don’t recognize this transaction. (This dispute requires additional information.
Please fill out all that applies in section 5 box 8.)
Other - Even though your dispute does not fall into one of the categories
above we may still be able to assist you. Please use the space below to
provide details. (Please attach any supporting documentation.)
Transaction Dispute Form v11072017 Page 1 of 2
Section 1
Section 2
Section 3
Section 4
Page 2 of 2
DISPUTE REASONS
I purchased: (select all that apply) Merchandise or Services from the merchant; however, the merchant misrepresented the terms. This is commonly
selected for a) sample/trial goods purchased that result in additional charges billed or b) lower interest rate solicitations or c) debt counselling services/outbound
telemarketing or d) computer antivirus solicitations.
What was agreed to at the point of sale:
Please describe what differs from the original agreement:
For contractual agreements in writing please attach a copy of the contract.
For online purchases please attach a copy of the terms and conditions that were agreed to at the original time of purchase.
For situations where terms and conditions were not presented, please check one of the following:
There were no terms and conditions presented at the point of sale. At no point in time was I redirected to an alternate site to review additional terms
and conditions.
There were no terms and conditions presented at the point of sale. I engaged with the merchant believing that I was dealing with: (insert merchant name
here) and at no point in time was I informed that I was dealing with an alternate company as shown on my statement.
I notified the merchant in accordance with their terms and conditions to cancel the recurring transaction; however, the merchant continues to bill me.
Cancellation date:
(Note: Cancellation date must be before the transaction date on your statement.)
I purchased: (select all that apply) Merchandise or Services from the merchant that were not as described or defective (includes counterfeit, shipped
merchandise, merchandise received damaged or not suitable for its intended purpose). Please provide a copy of the invoice received at the time of purchase.
We may also require proof from an expert in the field of the goods/service that the item is counterfeit. Please describe the mischaracterization, defect, or quality
issue in comparison to the bill of sale (invoice) and include any additional comments below:
(select all that apply)
Counterfeit Damaged Defective Quality
The amount of the charge was increased from $ to $ or my sales slip was totaled incorrectly.
(Please provide a copy of the sales slip that shows the correct amount.)
Select one only:
I did use my reservation; however, I have been billed an additional amount that I did not authorize.
Merchant justification for charge:
I notified the merchant on: to cancel the pre-authorized reservation. The merchant accepted my cancellation; however, the
merchant still charged my account. Please note the cancellation number: and provide proof of cancellation.
I was billed for loss, theft, or damage in the same transaction as the underlying initial service. (Please provide invoice/receipt.)
I have not received a credit for my cancelled transaction. Please choose one of the following:
I have returned merchandise on: and I have not received a credit on my account. (Please provide proof of return.)
The attached credit slip has not posted to my account. (Please provide proof of the credit issued.)
I attempted to make this purchase; however, the purchase was declined or the transaction was voided at the point of sale due to a system error but the transaction
was still billed to my account. Please choose one of the following:
I paid it by other means. (Please enclose proof of alternate payment ex: alternative statement, reference number or cash receipt.)
I abandoned the transaction.
Select one only:
I do not recognize this charge on my account. I contacted the merchant on: and the merchant was unable to clarify the reason
for the charge. (This is commonly selected when the merchant, amount, or date is familiar; however, it cannot be confirmed.)
I have NEVER engaged with this merchant. I certify that the charge listed above was not made by me or a person authorized by me to use my card, nor were the
goods or services represented by the transaction received by me or a person authorized by me.
Section 5
1.
3.
2.
4.
5.
6.
7.
8.
Transaction Dispute Form v11072017
First/Last Name:
(Please print clearly)
Signature:
(Required)
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