Merchandise/Service Not Received Dispute Form

This form must be completed and submitted as soon as a disputed is identified. Transaction dispute form must be received within 120 Calendar days from the original transaction (s) settlement date. Otherwise your dispute rights might be compromised.

CARDHOLDER DETAILS

Cardholder Name

Email Address

Cardholder Address

Account Number ( Can be found on your statement )

Total Amount Disputed

Merchant

REASON FOR DISPUTE

I , certify that the information herein provided is true and accurate.

I have examined the charges on my account, and I am disputing the following transaction(s) for the reason indicated below:

Did you subscribe to any service recently?

Yes No

If yes, have you attempted to unsubscribe?

Yes No

Did you attempt to resolve the matter with the merchant?

Yes No

If yes, please uploaded the correspondence from the merchant using the supporting document upload section at the bottom of this form.
If no, please complete the below section.

PRODUCTS/SERVICE

() I certify that the merchandise/service was ordered by me but was never received or was cancelled by me after processing. Or I certify that the item (s) ordered were received by me but was faulty/defective so was returned to the Merchant. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

Please complete the following:

*What was not received?

Merchandise Service

*Provide a detailed description of what was purchased and an explanation of the dispute:

*What was the expected receipt date and time?

Date

Time

Date Of Merchandise

Reason for Cancellation

Order Number

Shipping Address Provided

Date Of Cancellation

Date of last Contact with Merchant

DETAILS OF DISPUTED ITEMS

Transaction Date

Transaction Reference

Merchant/ATM Location

Foreign Amount

Local Amount

TOTALS

Upload Any Supporting Documents ( eg. Scans of orders , communications etc. )

You can select multiple files for upload.

I am enclosing copies of all pertinent documents to support this claim and I am willing to testify in court on the facts herein contained in this statement.

CUSTOMER SIGNATURE NAME ^*