Documente Academic
Documente Profesional
Documente Cultură
Date : ______________________________________
Cardholder’s Name : ______________________________________
Card Number : ______________________________________
I have examined the transaction(s) above and dispute the item(s) based on the following reasons
(Please check one)
I engaged in one transaction from the same merchant location, however, I was charged
for more than one transaction that neither I nor anyone else authorized. I certify that
my card was in my possession at the time of the transaction.
(REQUIREMENT: SALES SLIP OF THE VALID TRANSACTION)
REMARKS:
I hereby declare that all information indicated above is true and that my dispute will
only be processed upon completion of this form.
SIGNATURE:
__________________________________________
(Owner of the card where the disputed transaction was posted)