Dispute Duplicate Posting

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Dispute Duplicate Posting

Please fill out this form completely and accurately.

Only the person whose name is on the card should complete the form. Failure to answer all questions clearly will result in a delay in resolving your dispute.

Cardholder Name

16-Digit Card Number

How many transactions are you disputing?

One TransactionTwo TransactionsThree TransactionsFour TransactionsFive 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

In the space provided, please describe the reason for the chargeback:

Because you state you were billed twice for the same purchase, on what date did the original transaction occur?

MM slash DD slash YYYY

Please identify the date when the second transaction was posted

MM slash DD slash YYYY

What was the date when you attempted to resolve the issue with the merchant?

MM slash DD slash YYYY

In the space provided, please provide your (the cardholder's) attempt to resolve the dispute with the merchant:

Documentation Upload

Max. file size: 20 MB.

Please upload documentation to assist with the dispute process. Examples of documentation may include: receipts, screenshots of correspondence with customer service, emails, etc.

Signature

Date

MM slash DD slash YYYY

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