Microsoft word - visa transaction dispute form update.doc
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 email@example.com. Please keep a copy of this form for your records.
Kel y Goff Born 1980 Willemstad, Curaçao Netherlands Antilles Education Rhode Island School of Design Providence, RI Master of Fine Arts, Sculpture - With Honors 2009 New College of Florida Sarasota, FL Bachelor of Arts, Visual Art- Sub-concentration Biology/Chemistry 2002 Exhibitions The Wassaic Project Maxon Mills, Wassaic, NY 2012
Grateful Paws Dog & Cat Rescue, Inc. A No-Kill, Not for Profit, 501c3 organization AUGUST 2009 Issue #1 (and it is about damn time…) Editor: Jan Milbyer WELCOME TO “THE GRATEFUL PAW” Our first newsletter in almost 3 years -- A little History: Grateful Paws Dog & Cat Rescue, Inc. was founded in January 2006 in Fort Lauderdale, Florida. We are a no-kill, not-for-profit, 501c3 anim
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