Dispute Billed Incorrect Amount

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Dispute Billed Incorrect Amount

Cardholder Name

16-Digit Card Number

Please list the disputed transactions:

Merchant Name

Transaction Amount

Transaction Date

MM slash DD slash YYYY

Merchant Name

Transaction Amount

Transaction Date

MM slash DD slash YYYY

Merchant Name

Transaction Amount

Transaction Date

MM slash DD slash YYYY

Merchant Name

Transaction Amount

Transaction Date

MM slash DD slash YYYY

Merchant Name

Transaction Amount

Transaction Date

MM slash DD slash YYYY

Describe the reason for the Chargeback:

I have been billed for an incorrect amount. The Amount of Sales Draft was for the following amount:

The Amount Posted to my card was the following amount:

Have you provided (a required) copy of your unaltered receipt or documentation (e.g. a Rental agreement)?

YesNo

In the space provided, explain what are you disputing and why?

Is the transaction for lodging or vehicle rental?

YesNo

Identify which charges are being disputed:

When was the merchant contacted?

MM slash DD slash YYYY

In the space provided, describe your (the cardholder's) attempts to resolve the issue with the merchant:

Signature

Date

MM slash DD slash YYYY

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