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



Debit Card Information



Merchant Information



Dispute Details

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.

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.

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.

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

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.


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