Dispute Form subnav +

Dispute Form

Non Fraud (Non processed credit)

Please check if all fields are filled correctly

Personal Information

Select Card *

Enter 6 Last Digits (card)*

Name*

Last name*

Phone number*

E-mail*

I.D.*

Dispute Information

Dispute #1

Merchant name as appears on statement*

Amount in dispute*

Transaction date*

Cancellation date for the ordered service or good*

Attempt to resolve the dispute with the merchant (attach evidence or contact information)*

Copy of the credit receipt

Documentation showing the date in which the Credit will be processed (If available)

Upload Document

Want to add more disputes?

Yes

Dispute #2

Merchant name as appears on statement

Amount in dispute

Transaction date

Cancellation date for the ordered service or good

Attempt to resolve the dispute with the merchant (attach evidence or contact information)

Copy of the credit receipt

Documentation showing the date in which the Credit will be processed (If available)

Upload Document

Want to add more disputes?

Yes

Dispute #3

Merchant name as appears on statement

Amount in dispute

Transaction date

Cancellation date for the ordered service or good

Attempt to resolve the dispute with the merchant (attach evidence or contact information)

Copy of the credit receipt

Documentation showing the date in which the Credit will be processed (If available)

Upload Document

Want to add more disputes?

Yes

Dispute #4

Merchant name as appears on statement

Amount in dispute

Cancellation date for the ordered service or good

Transaction date

Attempt to resolve the dispute with the merchant (attach evidence or contact information)

Copy of the credit receipt

Documentation showing the date in which the Credit will be processed (If available)

Upload Document

Want to add more disputes?

Yes

Dispute #5

Merchant name as appears on statement

Amount in dispute

Transaction date

Cancellation date for the ordered service or good

Attempt to resolve the dispute with the merchant (attach evidence or contact information)

Copy of the credit receipt

Documentation showing the date in which the Credit will be processed (If available)

Upload Document

Notes

Please provide as many evidence as possible by uploading all your documents as this will speed up the Dispute process.

When you have filled in all the appropriate fields of the form, Click on the SUBMIT button below. Thank You!

I acknowledge being informed of the investigation fee, ($ 10.50) which will be automatically charged to my account when confirmed that the transaction(s) belong(s) to me. *