Online Cardholder Dispute Form

(for internal processing and tracking)
Yes No   If Yes, then this is of (e.g. 1 of 3) Only one transaction per form.
Cardholder Information
Disputed Transaction Information
$
Before Disputing Charge, The cardholder must make reasonable effort to resolve the dispute with the merchant.
Select Type of Dispute * (Choose One Only)
Did not recognize
Cardholder was billed twice for a single purchase
Membership cancellation
Merchandise was returned
Cardholder did not receive the merchandise
Cardholder was overcharged for the purchase
The credit posted as a sale
The credit did not post to cardholder's account
Cardholder paid by other means
Cardholder was charged for a hotel room, which was cancelled
Service Dispute
Other