ARKANSAS TECH UNIVERSITY P-CARD DISPUTE FORM
Purchasing Department Tel: 479-968-0269
Russellville, AR 72801-2222 Fax: 479-968-0633
Merchant Name: ______________________Post Date: __________ Amount: $ ___________
I have examined the charges made to my account, and I am disputing the above item for the
following reason. (P
LEASE CHECK THE APPROPRIATE BOX).
1.
The sales receipt was increased from $______________ to $ ______________.
2.
I did not authorize this charge.
3.
I have not received the merchandise. Delivery was scheduled _______________.
The ATU Purchasing Department contacted the merchant and requested that my
account be credited on ________________.
They spoke with: __________________________________________________
4.
The merchandise arrived: damaged and/or defective (circle one).
The ATU Purchasing Department contacted the merchant and requested that my
account be credited on _______________.
They spoke with: __________________________________________________
5.
Purchasing notified the merchant to cancel the order on ___________________.
Reason for Cancellation: ___________________________________________
They spoke with: __________________________________________________
6.
A credit was issued on _______________in the amount of $________________,
and it has not been posted to my account. Attached is a copy of the credit slip.
7.
The charge was billed twice to my account. See attached documentation.
8.
Merchandise was returned by ________________ on _____________________.
Return Authorization Number is: ____________________________.
9.
Other.
Cardholder’s Name: __________________________ Account No: __________________
Cardholder’s Signature: _______________________ Last 4 digits: __________________
P-Card Dispute Form MUST be submitted within 60 days from end of billing cycle.
