Fillable Transaction Dispute Form

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Transaction Dispute Form

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The Transaction Dispute Form form is 2 pages long and contains:

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  • 12 check-boxes
  • 57 other fields

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File type: PDF

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Transaction Dispute Form
Please complete all sections of the Transaction Dispute Form (as applicable).
If you have not done so already, you may also call us (see the back of your card OR the ‘Contact Us’ section on our website for our Customer Support
phone number) during business hours to file your dispute directly with us. (This form may still be requested by your customer service representative.)
Please provide all relevant information about your dispute, including all information you may have previously provided to a customer service
representative, if applicable.
Duplicate transaction
Card Details
Card Number
(Last 4 numbers on the front of your card)
(A customer service representative may have verbally provided this to you when
you filed your dispute. If you did not call, please write "N/A" in this section.)
Case Number
Disputed Transactions
Please list all transactions you wish to dispute. If you need to list additional transactions, please include an additional page.
Date
Amount
$
Merchant name
$
$
$
Reason for Dispute
Please check the box(es) most appropriate and attach any corresponding documentation (if applicable).
Please note that if the above transactions are identified as fraudulent, and your card/account has not yet been secured, it may require the
cancellation of your card and issuance of a new one.
I authorized and participated in the transaction(s) provided but have the following issue:
I have not authorized nor participated in the transaction(s) listed above and:
NOTE: Please include copies of any of the following: proof of credit/refund receipt, email, letter, sales receipt ATM receipt, proof that the
goods were returned, services were cancelled, or an attempt was made in addition to any details of the merchant’s response (as applicable).
I have done business with this merchant in the past, but I
did not authorize the above transaction(s).
I have never done business with this merchant.
Date
I have contacted the Merchant to try to resolve this
matter. My last contact was on:
Processed for the incorrect amount
Amount expected to pay $
Amount charged $
Credit not received
Expected refund amount $
Expected refund date
Paid by other means
By what other means did you pay?
(e.g. in cash, 1/2 on another card, etc.)
Date
I have not received the goods or services I paid for.
They were expected on:
I attempted to withdraw cash from an ATM:
Amount requested $
Amount received $
For transactions reported as not authorized, please confirm the following:
Date and time loss/theft occurred:
Date
Time
Police Report Details (if applicable)
What date and time did you report to the police?
Date
Time
Police ocer’s namePolice report number
Contact number Station/Location
I have my Card in Possession
Where do you keep a record of your PIN?
If Yes, please provide details
Ye s No
(memorized, written down, all details are helpful.)
Has your PIN been shared with anyone else?
(including family members)
Ye s No
Has your account login information been shared
with anyone else?
My Card was Lost/Stolen
Ye s No
Was your PIN lost/stolen as well?
If Yes, please provide any details below
Describe how and when you became aware of loss or theft
(please provide as many details as possible, e.g., scenario which loss or theft occurred etc., details will assist us in the investigation process).
Additional Information
Please provide any additional information that may be helpful in assisting with your dispute.
Signature
I certify that my statements in this dispute form are true, complete, and correct to the best of my knowledge and belief. I
understand that all statements made regarding this dispute may be investigated.
Signature Printed Name Date
Please return this completed form and any supporting documents to: Attention: Disputes, PO Box 5100, Pasadena, CA 91117
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Transaction Dispute Form

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Completed 5 April 2022

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