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    Transaction - Dispute - Written - Claim 2 PDF

    Uploaded by

    Sheila Likness
    This document is a customer statement of disputed transaction form. It provides sections for customers to fill out information about disputed transactions on their bank account, including whether a transaction was unauthorized, there was a cash discrepancy from an ATM, an incorrect transaction amount, a cancelled transaction, returned/defective merchandise, a duplicate transaction, paid by other means, non-receipt of goods or services, or other issues. The customer must provide their name, account and transaction details, and sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Transaction - Dispute - Written - Claim 2 PDF

    Uploaded by

    Sheila Likness
    217 views2 pages
    This document is a customer statement of disputed transaction form. It provides sections for customers to fill out information about disputed transactions on their bank account, including whether a transaction was unauthorized, there was a cash discrepancy from an ATM, an incorrect transaction amount, a cancelled transaction, returned/defective merchandise, a duplicate transaction, paid by other means, non-receipt of goods or services, or other issues. The customer must provide their name, account and transaction details, and sign and date the form.

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    Transaction_Dispute_Written_Claim 2.pdf

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    This document is a customer statement of disputed transaction form. It provides sections for customers to fill out information about disputed transactions on their bank account, including whether a transaction was unauthorized, there was a cash discrepancy from an ATM, an incorrect transaction amount, a cancelled transaction, returned/defective merchandise, a duplicate transaction, paid by other means, non-receipt of goods or services, or other issues. The customer must provide their name, account and transaction details, and sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    217 views2 pages

    Transaction - Dispute - Written - Claim 2 PDF

    Uploaded by

    Sheila Likness
    This document is a customer statement of disputed transaction form. It provides sections for customers to fill out information about disputed transactions on their bank account, including whether a transaction was unauthorized, there was a cash discrepancy from an ATM, an incorrect transaction amount, a cancelled transaction, returned/defective merchandise, a duplicate transaction, paid by other means, non-receipt of goods or services, or other issues. The customer must provide their name, account and transaction details, and sign and date the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    CUSTOMER STATEMENT OF DISPUTED TRANSACTION

    Please complete only ONE of the sections below. Use a separate form or additional pages to document each dispute. Once
    completed, please send this form and any supporting documentation to assist in the investigation to the following:

    Mail to: Member Services


    P.O. Box 417
    San Francisco, CA 94104-0417
    Fax to: 415-449-3446
    Email to: [email protected]

    If you have any questions, please contact [email protected] or 1-844-244-6363.

    Your Name: ____SHEILA LIKNESS ___________________________________________________________


    Account #: _________156150161537_________________________________________________________________________
    Amount: $_________$32.03 ___________________________________________________ Transaction Date:
    __ _10/19/19_______ _____________________________________________________ Post
    Date: _______________________________________________________________________________________________
    Reference Number (if available): _____________________________________________________________________________
    Transaction escription: _I have no idea who this company is or what it does. I looked it up Online and have never seen it before.

    Please complete only ONE of the sections below.

    ☐ SECTION 1: TRANSACTION NOT AUTHORIZED

    I certify that the charge(s) listed above was (were) not made by me nor a person authorized by me to use my card. I did not receive any
    goods or services from this transaction nor did any person authorized by me.

    1. My card was (Select one):


    ☐ IN MY POSSESSION ☐ NOT RECEIVED ☐ LOST ☐ STOLEN
    (If applicable) What day was your card lost or stolen?_________________________________________________________

    2. Do you know who made these transactions? (Select one):


    ☐NO ☐YES (If Yes, complete the following)
    Who do you think made or authorized these transactions? _____________________________________________________
    What is your relationship to this person? ____________________________________________________________________

    3. Have you given permission to anyone to use your card? (Select one):
    ☐ NO ☐ YES (If Yes, complete the following)
    Name: _________________________________________________ Relationship: __________________________________

    4. When was the last time you used your card?


    Date/Time: _____________________________________________ Amount: $_____________________________________
    Merchant Name or ATM Location: _________________________________________________________________________

    5. Where do you normally store your card? ____________________________________________________________________

    6. Where do you normally store your PIN? _____________________________________________________________________

    7. Please list other items that were lost or stolen, including your mobile phone or any additional cards (if applicable):_________
    _____________________________________________________________________________________________________

    8. Have you filed a police report? (Select one)


    ☐ NO ☐ YES (If Yes, complete the following)
    District/Officer name: ___________________________________________________
    Report number: _________________________________________ Suspect name: _________________________________

    Page 1 of 2
    CUSTOMER STATEMENT OF DISPUTED TRANSACTION

    ☐ SECTION 2: ATM – CASH NOT RECEIVED

    I requested $ ________________________ from the ATM however I received $ ________________________.


    I am disputing the amount of $ ________________________ as this amount was not received.

    ☐ SECTION 3: INCORRECT TRANSACTION AMOUNT

    The dollar amount of the transaction was increased from $ ________________________ to $ ________________________.
    I am enclosing a copy of my debit card sales receipt, which reflects the correct dollar amount.

    ☐ SECTION 4: CANCELLED TRANSACTION

    I dispute the entire charge or a portion of it in the amount of $ ________________________. I contacted the merchant on
    ______________________ (date), but no credit has been applied to my account. I received the following confirmation number when I
    cancelled the service: _________________________________.

    ☐ SECTION 5: RETURNED OR DEFECTIVE MERCHANDISE

    All or part of the shipped or delivered merchandise was defective or damaged when I received it. I returned the merchandise on
    _______________________________ (date), but I have not yet received a credit. The tracking number for this shipment is:
    ___________________________________. I contacted the merchant on _______________________________ (date) and received the
    following response: ____________________________________________________________________________________.

    I am enclosing a detailed statement describing the defects of the merchandise and am enclosing a copy of my proof of return list of the
    merchandise received, the items returned, and the cost of each item.

    ☐ xx 6: DUPLICATE TRANSACTION

    The above transaction is a duplicate of an authorized transaction that took place on October 19th 2019 (date). The reference number
    for the authorized transaction is: ________________________.

    ☐ SECTION 7: PAID FOR GOODS BY OTHER MEANS

    I made the above transaction, but paid for it by ______________________________________ (list form of payment used: cash, another
    debit or credit card, etc). I am enclosing a copy of the receipt showing the correct form of payment.

    ☐ SECTION 8: NON-RECEIPT OF GOODS OR SERVICES

    I have never received the merchandise. I expected to receive it during the week of ________________________ (date). I contacted the
    merchant on ________________________ (date), and received the following response: _______________________________________
    _____________________________________________________________________________________________________________.

    ☐ SECTION 9: OTHER (not classified above)

    Please describe the situation and provide any information that would be helpful to the investigation:
    ______________________________________________________________________________________________________________
    ______________________________________________________________________________________________________________
    ______________________________________________________________________________________________________________

    Cardholder signature: ____________________________________________________ Date: ___________________________


    Contact number (during the hours of 8am-5pm CST): ___________________________________________________________

    Page 2 of 2

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