Transaction Dispute Form

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:

Please check the most suitable reason that applies to this dispute:

() I certify that the transaction (s) listed were not authorized by me or any authorized users of the account, nor did I grant any person permission to engage in the transaction (s), nor did I benefit in any way from the transaction (s). I therefore do not accept responsibility for same.

() I acknowledge participation in at least one transaction at the mentioned Merchant. However, I certify that I neither engaged in nor authorized the transaction in question. I therefore certify that the signature appearing on the disputed sales receipt is not mine. IF THIS IS THE CASE, 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.

() I certify that the transaction appears more than once on my Statement; however, I certify that only one transaction was made by me. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

() I certify that I never used, nor have I given any person my consent or authority to use my Card or Pin to withdraw funds from my account. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.

() I certify that I attempted to retrieve funds from the ATM and was unsuccessful because the ATM did not dispense cash, retracted the cash or disbursed a partial amount of the full cash amount requested. IF THIS IS THE CASE, PLEASE COMPLETE THE BELOW SECTION.