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The document is a transaction dispute form for credit card holders to report unauthorized or erroneous transactions. It includes sections for personal information, details of disputed transactions, reasons for disputing, and required signatures. Important notes highlight the need for supporting documents and the timeline for reporting disputes to the bank.

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pratapmahata78
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23 views

tdf

The document is a transaction dispute form for credit card holders to report unauthorized or erroneous transactions. It includes sections for personal information, details of disputed transactions, reasons for disputing, and required signatures. Important notes highlight the need for supporting documents and the timeline for reporting disputes to the bank.

Uploaded by

pratapmahata78
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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TRANSACTION DISPUTE FORM

Date: ______________

Credit Card No: ______________________________ Telephone/ Mobile No: _________________

Cardholder Name:____________________________ Email Id: ____________________________

Add On Credit Card No. : __________________________

Add-on Cardholder Name: __________________________

Details of Disputed Transactions:

S.No Statement Transaction Merchant Name Transaction Disputed


date Date Amount. (INR) Amount. (INR)

Name of Merchant Country___________


Acquirer Reference NO.______________

I am disputing the above listed transaction(s) for the reason (ticked) and mentioned below:-

UNAUTHORIZED TRANSACTION 
I neither made nor authorized above transaction.

LOST/SUSPECTED FRAUD 
My card was (circle one of the following choices below)
A. Lost/Stolen: on Date: __________ Location: _____________
B. Card Never Received
C. Card was in my possession at the time of fraudulent use

MULTIPLE PROCESSING 
I have been charged ----- times for the same transaction. I authorized only one transaction on------
(mention the date). The original amount appeared on my------ (indicate month) statement (enclose
copy of statement)

DIFFERENCE IN AMOUNT 
The amount on my sales slip differs from the amount billed and shown in------ statement(indicate
month) . I am attaching my receipt showing the correct amount. The difference in amount
is____________

CANCELLED TRANSACTION 
I cancelled this transaction on ____________(indicate date).I am attaching receipt indicating the
specific reason for the cancellation and cancellation reference numbers.

Cont….
DEFECTIVE MERCHANDISE 
I am disputing the quality of goods/services I received from merchant. I have contacted the
merchant/retailer . The response to my request for refund, is stated on annexure attached herewith.
CREDIT NOT RECEIVED 
I was given a credit slip in the amount of _____________on_________ (DD-MM-YYYY) by the merchant
retailer which has not yet appeared on my billing------- Statement (indicate month) The copy of the credit
slip is attached.

PAID BY OTHER MEANS 


I paid for the transaction by Cash Cheque Draft Other credit card. I attach
cash receipt or copy of cheque / Cheque no. alongwith Bank statement orother credit card
statement.

MERCHANDISE RETURNED 
I have returned the merchandise and requested a refund from the Merchant retailer and have forwarded a
copy of the proof of return to him. I attach proof of return herewith.

NOT AS DESCRIBED 
The goods/services are different from what was ordered or described. On attached sheet I have explained
what was expected, what was received, and indicated my attempt to return the goods. The proof of return
is also attached.
GOODS / SERVICES NOT RECEIVED 
I have not received the goods/services and for that reason,I contacted the Merchant/retailer
on___________(DD-MM-YYYY) . The merchant response to my request for a refund or delivery date is
given on separate attached sheet .The copy of letter to the merchant attempting to resolve the dispute is
enclosed.

ATM DISCREPANCY 
The amount on my ATM slip differs from the amount billed in statement. Attached is my
receipt showing the correct amount. The difference in amount is ______________ or I
did not receive cash from ATM.

ANY OTHER
(Give full details)

Primary Cardholder Signature: _________________________________

Add-on cardholder Signature: ____________________________(mandatory if the


transactions disputed are done through the Add on Card)

IMPORTANT NOTE
• Cardholder is requested to submit card statement highlighting disputed transaction and
required documents wherever it is requested
• After dispute charges are resolved, should such charges recur in the statement, you are
requested to intimate the Bank for these disputed charges vide this form within 30 days of
statement date to enable us to take up the dispute with the member banks. After the lapse of
30 days, it will be construed that all the charges are acceptable and in order.
• A retrieval fee as prescribed in schedule of charges will be levied on per transaction basis to
your account

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