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.
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.
() 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?
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.