Submit a Debit Card Dispute

Use this form to submit a claim for any charges on a card that you would like to dispute.

Prior to disputing charge(s), you must make every effort to resolve the dispute with the merchant.

Your Information

Contact Name Email

Debit Card Information

Transaction ID Debit/Credit Card # Account Name Account Number Phone Number Email Address

Merchant Information

Merchant Name Amount Post Date

Dispute Details

Type of Dispute

You did not authorize or participate in this transaction(s).

Cardholder must contact the merchant prior to disputing the charge, and must provide proof of cancellation within the free trial period.

Cardholder must attempt to return the merchandise prior to exercising this right. After submitting this form, please reply to the confirmation email that you will receive with an attachment containing signed proof of return, credit slip or postal receipt.

Cardholder must attempt to contact the merchant prior to disputing this charge.

You must attempt to contact the merchant prior to disputing the charge.

Item(s) Ordered

After submitting this form, please reply to the confirmation email that you will receive with an attachment containing a copy of the signed sales receipt.

Cardholder must attempt to contact the merchant prior to disputing the charge. Only one transaction is valid but posted more than once. All cards issued to the cardholder are in their possession.

Invalid transaction amount Invalid transaction post date

Valid transaction amount Valid transaction post date

Expected delivery date

Merchant was contacted on

What as the outcome from contacting the merchant?

Method of Enrollment Free trial enrollment date Free trial offer was good through

After submitting this form, please reply to the confirmation email that you will receive with an attachment containing a copy of a letter, email or fax notifying the merchant of cancellation.

Merchant was notified on Reason for Cancellation

Cardholder must attempt to contact the merchant prior to disputing this charge.

Expected delivery date Amount requested Amount received

Cancellation date Cancellation number

Reason for return Merchandise was received

Merchandise was returned

Amount requested Amount received

Merchant’s response

Was the cardholder advised of a cancellation policy?

After submitting this form, please reply to the confirmation email that you will receive with an attachment containing a copy of the dated credit slip or notice of credit from the merchant and a detailed explanation of the dispute.

After submitting this form, please reply to the confirmation email that you will receive with an attachment containing a detailed description of your dispute, and the steps taken to resolve it with the merchant on a separate sheet.

Thank you! Your submission has been received!

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