Dispute Returned Merchandise

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Dispute Returned Merchandise

I have returned merchandise, cancelled a service or reservation and requested a credit. 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

In the space provided, please tell us what you purchased:

When did you contact the merchant regarding this purchase?

MM slash DD slash YYYY

Was a credit voucher, letter of credit, voided transaction receipt, or refund acknowledgement given?

YesNo

What was provided by the merchant?

Credit VoucherLetter of CreditVoided Transaction ReceiptRefund Acknowledgement

When was the merchandise returned, credit issued, or cancellation accepted?

MM slash DD slash YYYY

Were you (the cardholder) aware of the merchant's refund policy?

Yes, I was awareNo, I was not aware

Please Explain Your Understanding of the Merchant's Refund Policy:

Return Merchandise Authorization or Cancellation Number:

What was the Date Delivered?

MM slash DD slash YYYY

Name of the Shipping Company:

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

Shipping Tracking Number:

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

In the space provided, please provide the address where you shipped the return:

Who signed for the package?

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

Signature

Date

MM slash DD slash YYYY

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