Cardholder Merchant Dispute Affidavit

CARDHOLDER MERCHANT DISPUTE AFFIDAVIT

Cardholder Name ______Member Number ______

Card number ______-______-______-______Employee Name______

Merchant Name ______Amount ______Transaction date______

Please thoroughly read this entire form, and then choose the ONE category that best describes your dispute:

_____Thecharge posted to my account twice, but I only authorized one purchase. The valid charge posted on ______. My debit card(s) are still in my possession.

(Attach a copy of the receipt showing the initial purchase.)

_____ The charge posted to my account for an amount different from the amount on my receipt.

(Attach a copy of the receipt showing the difference.)

_____I have not received expected goods or services. The expected date of delivery/completion was ______. I have contacted the merchant and the response was ______.

(Attach a copy of the receipt showing the purchase.)

_____The merchandise received was not as described, poor quality, damaged, or unsuitable for the purpose intended. I returned (or attempted to return) the merchandise on ______. I have contacted the merchant and their response to the return was ______.

(Attach a copy of the receipt showing the purchase. Please provide details of what was wrong with the merchandise on the second page of the form, and include proof the goods were returned to the merchant, such as a tracking number.)

_____I have returned merchandise to the merchant.

(Attach a copy of the receipt showing proof of shipping.)

_____I contacted the merchant on to attempt to returnmerchandise. I did not receive a credit slip because ______. I was/ was not (circle one) informed of the merchant’s return policy, and their response to the return was: ______.

(Attach a copy of the receipt showing the purchase.)

_____I cancelled the transaction with the merchant on ______. I was/ was not (circle one) informed of the merchant’s cancellation policy, I have contacted the merchant and the response to the cancellation was ______.

(Attach a copy of the receipt showing the purchase. Please include any contracts or correspondence to and from the merchant.)

_____I cancelled the hotel reservation on ______. My cancellation number is ______

(If no cancellation number was provided, please provide a telephone statement showing the cancellation call to the merchant.)

NOTE: Please provide a detailed explanation of the dispute

MUST BE COMPLETED BY CARDHOLDER

______

______

A $30.00 FEE WILL BE CHARGED TO THE MEMBER IF THE DISPUTE IS DENIED AND IT IS DETERMINED

THAT THE TRANSACTION(S) WAS VALID

I declare under the penalty of perjury that the foregoing is true and correct.

Cardholder Signature ______Date______

NOTARY ACKNOWLEDGEMENT

STATE OF TEXAS, COUNTY OF ______

This Affidavit was acknowledged before me on this ______day of ______, by ______, who, being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing Affidavit subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.

______ Notary Public

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