BUSINESS PROCUREMENT CARD DISPUTE FORM
Name
Account Number
Department Business Phone
Merchant
Name
Amount of Dispute
Date of Transaction Reference Number of Transaction from Statement
Please mark the appropriate dispute reason listed below and, if indicated, provide the requested documentation.
I do not recognize the above merchant. I am asking that the merchant provide me with more information to help identify whether or
not the charge is valid. All valid cards issued to this account are in my possession.
Although I did engage in the above transaction, I am disputing of the above charge. I have contacted the merchant and
attempted to resolve the matter. I have provided the details below.
Incorrect Amount: Must provide copy of receipt. I was billed
but should have been billed .
Duplicate Posting. The original transaction posted to my statement for
on
.
I returned the merchandise to the merchant on
. The reason for return is listed below. Must provide proof of return.
I have a credit slip and the credit has not posted to my acc
ount. Must provide copy of credit slip.
To best of my knowledge I, nor anyone authorized by me, received the goods or services represented by the charge. I also certify that
I, nor anyone with my permission, engaged with the above merchant in any manner.
I have not received the merchandise and it was to be delivered on . Must give dates when the merchant was contacted to
check on the status of the order & their response below.
I cancelled a guaranteed late arrival hotel reservation on at , the cancellation # is:
Other. Details of the dispute have been provided below.
SEND THIS FORM TO:
Accounts Payable
ATTN: Travel & Card Program Coordinator
Administration Building 316
Warrensburg, MO 64093
660-543-4889
Cardholder’s Signature & Today’s Date
ACCOUNT INFORMATION
TRANSACTION INFORMATION
ADDITIONAL INFORMATION REGARDING THE DISPUTED CHARGE
