Dispute Quality Not as Described

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Dispute - Quality Not as Described

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

Although I did engage in the transaction(s), I am disputing the quality of the goods and services I received. I have contacted the merchant and either have not received credit or I am still unsatisfied. Documentation for my claim is attached:

What was ordered or purchased?

Describe why the merchandise or service was not as described or unsuitable for the purpose intended:

What date did you receive the merchandise or service?

MM slash DD slash YYYY

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

Who did you speak with when attempting to resolve the dispute? (Provide a name)

When did you contact the merchant?

MM slash DD slash YYYY

What was the merchant's response?

What was the date returned, attempted return, or notification the goods were available for pickup?

MM slash DD slash YYYY

What is the return merchandise authorization number?

What was the date the merchandise was delivered back to the merchant?

MM slash DD slash YYYY

Please provide the name of the shipping company:

This is required for non-face-to-face returns

What was the shipping tracking number on the return?

This is required for non-face-to-face returns

What was the address for the return shipment?

This is required for non-face-to-face returns

Who signed for the package?

For quality disputes, if face-to-face, please include documentation from an expert or professional that supports the cardholder's dispute about the level of quality or misrepresentation described on the original receipt (on their letterhead, or a copy of their license or business card)

Documentation Upload

Max. file size: 20 MB.

Please upload all documentation that will assist in resolving this dispute. This could include receipts, letters, screenshots of customer support chat history, emails, etc.

Signature

Date Submitted

MM slash DD slash YYYY

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