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

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:

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 the expected receipt date and time?

DETAILS OF DISPUTED ITEMS

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.