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Cardholder Name ________________________ Dept.___________________________ Ext.________  

Vendor Name ___________________________ Trans. Date _________ Statement Date ____________

Amount Disputed ______________ Trans. # ___________________ Reference # _________________

Check the description most appropriate to your dispute:

_____ Alteration of Amount:  The amount of the sales draft has been altered from $ ________ to $ ________.  (Please include copy of sales draft.)

_____ Cardholder Dispute:  I did participate in the above transaction, however, I dispute the entire charge, or a portion, in the amount of $ ________ because:

_____ Credit Not Received:  The vendor has issued me a credit slip for the transaction listed above, however, the credit has not posted to my account.  The date on the voucher is between 30 and 90 days old.  (Please include a copy of the credit voucher.)

_____ Inadequate Description/Unrecognized Charge:  I do not recognize this charge.  Please supply a copy of the sales draft for my review.

_____ Merchandise Not Received:  My account has been charged for the above transaction, but I have not received this merchandise.  I have contacted the vendor.

_____ Merchandise Returned:  My account has been charged for the transaction listed above, but the merchandise has been returned.  Provide a description of the circumstances.  (Please include postal receipt for the return if applicable.)

_____ Multiple Charge:  The above transaction represents multiple billing to my account.  I only authorized one charge from this vendor for $ _________.  I am still in possession of my card.

_____ Order Canceled Prior to Shipment:  My account has been charged for the above transaction, but I have since contacted this vendor and canceled the order.  I will refuse delivery should the merchandise still be sent.

_____ Unauthorized Mail or Phone Order:  I certify the charge listed above was not authorized by me or any authorized user of this account.  I have not ordered merchandise by phone or mail, or received goods and services as represented above.

_____ Other:

_____ I am no longer disputing this charge.

Cardholder Signature _______________________________________________________

            Merchant / Bank / Individual Contacted __________________________________

Conversation Summary: (Please use additional sheet for summary.)

Revised 6/06