To,

The Manager Operations

ICICI Bank Limited
ICICI Bank Tower, C – Wing
Autumn Estate, Near Chandivali Studio
Chandivali Farm Road,
Opp. Mhada Colony, Chandivali
Andheri (East), Mumbai 400072 Date: 21-11-2023

CardMember Dispute
Form

CARD N 3 5 6 2 0 5 0 0 7 2 4 0 0 68

DETAILS OF DISPUTED ITEM Charge details shown in my statement dated 21-11-2023

TRANSACTION MERCHAN TRANSACTION DISPUTE

DATE T NAME AMOUNT D
AMOUNT
21-11-2023 Phonepe 49980 49980
21-11-2023 Phonepe 26520 26520

I am disputing the transaction(s) listed above for the reason as follows and request you to settle the cases
 I have neither incurred nor authorised the above transactions
 I have been charged twice for the same transaction
 I have incurred one transaction dated 21-11-2023 at the above merchant establishment.
However, I have not incurred or authorised the transactions listed above.
Attached is my copy of chargeslip for the genuine transaction.
 The transaction amount incurred was 76500
, but I have been billed for 76500 Attached is my copy of
chargeslip showing the actual amount.
 I have never received the ordered merchandise whose delivery date was
21-11-2023
Attached is a copy of my letter to the merchant attempting to resolve the dispute.
 My hotel reservation was cancelled on NA . However I have been billed a No-Show Charge. The
cancellation number is .
 I already paid the transaction amount by other means and the evidence is enclosed.
Paid by Cash/ Cheque/ DD/ Credit Card # dated 21-11-2023
Enclosed is a copy of my Cash Memo/ Bank Statement/ Payment Counterfoil/ Card
Statement.
 The credit voucher was issued on NA but not processed to my
account. Attached is a copy of my Credit/ Refund Slip/ Cancellation letter from
merchant establishment.
 ATM Transaction attempted by me did not dispense cash for Rs. NA
 ATM Transaction attempted by me partially dispensed cash for Rs. NA
Attached is my copy of ATM slip.
 Others ( any additional comments)

Mandatory: FOR RESOLUTION OF THE DISPUTE, PLEASE FORWARD THE DULY SIGNED AND FILLED
CDF ALONG WITH THE APPLICABLE DOCUMENTS MENTIONED ON PAGE NO. 2

1
 List of Documents

To initiate investigation for the disputed transaction, the Cardholder needs to submit a copy of the
below mentioned documents.

Type of
Type of Documents
transacti
Card Required
on
 Duly filled Customer Dispute Form (CDF). CDF to be signed by
the Card Holder of the card for which dispute is being raised.
 Copy of face of the Card on which dispute is being raised
Copy of any one Photo ID proof mentioned below (Please carry the
Debit original document for verification): Domestic
Card/  Passport &
Credit  PAN Card Internation
Card  Voter ID Card al
 Driving licence
 Government ID Card
 Photo Ration Card
 Senior Citizen ID Card

To establish proof of presence, please provide the following documents. In case of Joint
Account/transaction is done using Add-on Credit Card, the proof of presence will be required for all
holders

Type of
Type of Documents
transacti
Card Required
on
1. If the cardholder was in the same location where disputed
transaction took place, please provide any of the below mentioned
proof which substantiates the claim.
 HR letter confirmation, if the cardholder was present in office on the
date of disputed transactions. HR letter should be on Company
letter head duly signed and stamped Domestic
 Statement of usage of any other bank card on date of disputed &
Debit transactions confirming cardholder’s availability in that particular Internation
Card/ place and city al
Credit  Hotel stay proof on date of disputed transactions confirming
Card presence in that particular place and city
 Itemised postpaid mobile bill of the cardholder for the period
when disputed transaction has taken place
2. If cardholder was not present in the country where the disputed International
transactions took place,
 Please provide a copy of all the pages of the passport.
Debit Domestic
 Police Complaint copy, if lodged
Card/ &
Credit Internation
Card al

Sai Manikanta
Cardholder’s Signature