Dispute Non Receipt of Merchandise

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Dispute Non Receipt of Merchandise

Cardholder Name

16-Digit Card Number

How many transactions are you disputing?

OneTwoThreeFourFive

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 not received the merchandise I ordered or expected to receive on the following date and have contacted the merchant for a credit:

MM slash DD slash YYYY

What did you purchase?

What was the expected date of receipt?

MM slash DD slash YYYY

When did you contact the merchant?

MM slash DD slash YYYY

Describe your (the cardholder's) attempt to resolve the issue with the merchant:

In the space provided, please list telephone calls, emails, web-based customer support that you engaged in, as well as the date/time of these interactions, and the response you received from the merchant.

Upload any supporting documentation regarding your dispute(s):

Max. file size: 20 MB.

Signature

Date

MM slash DD slash YYYY

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