Dispute Paid for by Other Means

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Dispute - Paid for by Other Means

Please fill out this form completely and accurately.

Only the person whose name is on the card should complete this 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

Describe the reason for the Chargeback:

I paid for this purchase by other means. How was the product or service paid for?

Describe the details of the billing dispute. You (the cardholder) must provide proof that the goods or services were paid for by other means, such as front and back of cancelled check, cash receipt, a debit card slip or credit card slip/statement.

When was the merchant contacted?

MM slash DD slash YYYY

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

Signature

Date

MM slash DD slash YYYY

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