Transaction Dispute Form

Instructions:
Please submit a Transaction Dispute Form for each transaction that is being disputed. Transaction disputes must be submitted and received by the Dispute Resolution Team within 60 calendar days from the date on the company’s account statement.

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Note: If you are attaching documentation that contains sensitive, non-public information, be advised that transmitting information via this method is not a secure means of communication, so do not attach documentation that includes sensitive information such as full credit card numbers, social security numbers, bank account details, etc

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Transaction Dispute

Transaction Dispute Form

Company Name*
Account Code*
Address*
Street Address Address Line 2
City*
State*
Zip/Postal Code*
Country*
Contact Name*
First Last
Contact Phone*
Email
Please identify the transaction that is being disputed and be sure to include any supporting documentation. Refer to your account statement for the following information:
Last 4 digits of card number*
0 of 4 max characters
Posted Date*
MM slash DD slash YYYY
Disputed Amount*
Merchant Name*
Merchant Contact Number
Merchant Email
Do you believe the card information associated to the transaction in dispute was compromised?*
- Yes
- No
Dispute Details

Common Dispute Reasons & Documentation Guidelines can be viewed here.
Drop files here or

Max. file size: 256 MB.
Please select the statement that best describes the nature of the dispute.*
If other please describe the nature of the dispute.
By checking this box, I certify that the information I provided is accurate to the best of my knowledge.*
- Yes
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Phone
This field is for validation purposes and should be left unchanged.