Credit Card Dispute Form
Please provide supporting documentation with this form to assist us in our investigation and to substantiate your claim.
Please read each category in its entirety and ensure you have provided all requested information. We may need additional
information from you at various stages of your claims process. Please ensure your contact information is accurate.
Most transactions require written notification of a dispute within sixty (60) days of the first statement on which the error or
problem first appeared.
Fraud information: If you believe that there has been possible unauthorized use of your credit card account, please contact us
immediately at the number on the back of your credit card.
The following information is necessary to investigate and process your dispute:
Credit Card number: ___________________________ Transaction date: _ ___ /____ /____ Posting date: _ ___ /____ /____
Disputed amount: $_ ___________________________ Merchant name:�������������������������������������������
Contact phone number: _______ –_______ –___________ Email:���������������������������������������������������
Select ONE statement below that best describes the nature of your dispute.
Merchandise or Service Orders
I did NOT receive the service I contracted for with the merchant. Describe service you did not receive.
I did NOT receive the merchandise that was to be shipped. Expected delivery date: ___ /____ /____ .
he service or merchandise I received was not as described. Describe the service or merchandise you were to receive, and how
T
it differed from what you ordered or contracted for. Attach documentation (i.e. copies of sales receipts, emails, contracts, etc.)
to support your claim.
Returns and Cancellations
I returned the merchandise on _ ___ /____ /____ , but the credit was not applied to my credit card account.
Attach proof of return. Explain why you returned the merchandise (i.e., defective).
I canceled a service or merchandise order on ____ /____ /____ , but the credit was not applied to my credit card account.
Provide evidence of cancellation.
Credit Not Applied
I was issued a credit which appears on my credit card account as a debit. Attach evidence to support your claim.
I have a credit receipt, but the credit was not applied to my credit card account. Attach evidence to support your claim.
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General Transaction Issues
y credit card account was charged more than once for the same transaction. I authorized one charge for $���������������� .
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I certify that my card was in my possession at the time of the duplicate charge. Date of duplicate charge ____ /____ /____ .
I was billed the wrong amount. The correct amount is $_ ___________________ . Attach evidence to support your claim.
I only authorized this merchant to charge me one (1) time. I did not authorize any other charges from this merchant.
I notified the merchant on ____ /____ /____ by phone/mail that I wished to cancel a recurring charge.
Merchant Cancellation #___________________________ Merchant Response������������������������������������
I did NOT authorize this charge to my credit card account. I certify that the charge was not made by me or any person authorized
by me to use my credit card. No goods or services have been received.
I made a credit card payment on ____ /____ /____ that is not reflected on the statement received on ____ /____ /____ .
Attach copy of proof of payment (processed check, proof of payment from Online Banking, etc.).
Other. Describe in detail and attach supporting documents as to why you are disputing the charge.
Please also provide details on any attempts to resolve this issue directly with the merchant.
Use this section to provide any additional information.
Signature: ____________________________________________ Date: ___ / ___ / ___
Please return your completed form and supporting documentation to us by mail, fax or email to:
Credit Card Claims Operations
P.O. Box 7092
Bridgeport CT 06601-3211
Fax number: 888-727-0028 / 781-655-5418
Email: [email protected]
If you have any questions or concerns about this matter or your account, please contact our Credit Card Claims Department
at 877-945-4060 Monday through Friday from 8:30 am to 5:00 pm ET.
Sincerely,
The Credit Card Claims Operations Department
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