Dispute for Participated in a Transaction and Billed an Unauthorized Transaction

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Dispute Engaged in Transaction and Billed for Unauthorized Transaction

Cardholder Name

16-Digit Card Number

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 did engage in a transaction with the merchant, but I was billed for a transaction(s) that I did not engage in, and did not authorize anyone else to use my card.

Were you in possession of the card at the time of the transaction?

YesNo

What is the description of the unauthorized transaction?

In the space provided, include descriptions such as the amount of the transaction(s) as well as any dates when transaction(s) occurred.

When did you (the cardholder) attempt to resolve the issue with the merchant?

Provide details of your (the cardholder's) attempt to resolve the issue with the merchant:

This could include information about telephone calls, email correspondence, and/or web-based customer support as well as dates/times of attempts and responses.

Was this a face to face transaction?

YesNo

Have you provided the (required) copy of your unaltered transaction receipt?

YesNo

Please Upload the required copy of your unaltered transaction receipt

Max. file size: 20 MB.

Signature

Date

MM slash DD slash YYYY

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