Microsoft word - visa transaction dispute form update.doc

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If you believe a transaction on your statement is in error, you must attempt to resolve with the merchant before initiating a dispute. After you have attempted to resolve with the merchant and feel you still need assistance, please complete and sign this form with your detailed information. Provide copies of all documentation that will help us investigate your dispute (i.e. contracts, invoices, detailed letter, cancellation number, etc.). Do not mail your dispute form or letter with your payment. Please check only one box. Do not alter wording on this form. Your name: _______________________________________ Account/Card Number: ____________________________________ Amount:_____________________Transaction Date: ___________________________ Post Date: __________________________ Reference Number: ____________________________________________Merchant Name: ________________________________ Please tell us why you think the item noted is in error. Check only one box and include specific details. I certify that the charge in question was a single transaction, but was posted twice to my statement. I did Tran Date ____________ Post Date _____________ Sale#1 $_____________ Reference #_________________ Tran Date ____________ Post Date _____________ Sale#2 $_____________ Reference #_________________ I was issued a credit slip that has not shown on my statement. Must provide a copy of your credit slip Attached is my credit slip which was listed as a charge on my statement. I have not received the merchandise that was to be shipped to me on ___________ (date). I have asked the merchant on _____________ (date) to credit my account. Confirmation# _______________________. Merchandise that was shipped has arrived damaged and/or defective. I returned it on ___________ (date) and asked the merchant to credit my account. Enclosed is my return receipt copy or tracking number for this return. # _______________ I have returned the merchandise on _________ (date) because ________________________________________. I notified the merchant on _____________ (date), cancellation # ______________ to cancel the preauthorized monthly billing. The reason for my cancellation is ____________________________________. Please allow 10 days to cancel a recurring charge so the merchant has time to remove your information from their system. I was charged for a hotel room, which I cancelled on (date) _________. Please note cancellation # ________1___________ or see attached phone bill showing the date and time of cancellation. (Proof of cancellation is a must) The amount of the charge was increased from $__________________ to $_______________ or my sales slip was added incorrectly. Enclosed is my copy of the sales draft that shows the correct amount. Although, I did engage in a transaction with the merchant, I was billed for _________transaction(s) totaling $_____________ that I did not engage in, nor did anyone else authorized to use my card. I do have all my cards in my possession. Enclosed is a copy of my sales slip with the valid charge. My card was used to secure this purchase but payment was actually made by other means. Attach copies of the cancelled check (front and back), cash receipt or other credit card account statements showing the transaction. I certify that I have cancelled my recurring payment and it is still being debited from my account. Please Date cancelled: ______________Amount:___________________________ Date last debited from account: ________________ *******The stop pay request will only stop exact dollar amount matches Other: Please explain: _______________________________________________________________________________ _________________________________________________________________________________________________ Signature (required) _______________________________________________ Date: __________________________________ Home Telephone: ______________________________ Work Telephone: _____________________________________________ Please return the dispute form and/or letter to Cards Risk Management Team by : mail , P.O. Box 10409, Des Moines, Iowa 50306; fax, (515) 457-2074; or email to risk@themembersgroup.com. Please keep a copy of this form for your records.

Source: http://www.mayocreditunion.org/media/doc/Visa_Dispute_Form.pdf