Dispute Form subnav +

Dispute Form

Non Fraud (Transaction paid by other means)

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

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

Proof of payment by other means (Receipt of payment made in cash/check/other statement)

Upload Document

Want to add more disputes?

Yes

Dispute #2

Merchant name as appears on statement

Amount in dispute

Transaction date

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

Proof of payment by other means (Receipt of payment made in cash/check/other statement)

Upload Document

Want to add more disputes?

Yes

Dispute #3

Merchant name as appears on statement

Amount in dispute

Transaction date

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

Proof of payment by other means (Receipt of payment made in cash/check/other statement)

Upload Document

Want to add more disputes?

Yes

Dispute #4

Merchant name as appears on statement

Amount in dispute

Transaction date

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

Proof of payment by other means (Receipt of payment made in cash/check/other statement)

Want to add more disputes?

Yes

Dispute #5

Merchant name as appears on statement

Amount in dispute

Transaction date

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

Proof of payment by other means (Receipt of payment made in cash/check/other statement)

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. *