Dispute Form
Full names
*
You must fill the value
Identify number
*
You must fill the value
Contact number
*
You must fill the value
Email adress
*
You must fill the value
Card number / virtual number for online transactions
*
You must fill the value
Date of disputed transaction
*
You must fill the value
Amount
*
You must fill the value
Transaction Type ATM/POS/Online
*
You must fill the value
Country of dispute
*
You must fill the value
Merchant / ATM name
*
You must fill the value
Description of what happened ?
*
You must fill the value
Description of goods / services purchased ? (for Online/POS)
You must fill the value
Check the right boxes
*
Customer did not perform/ is not aware of this transaction
The card was used twice, only one of the transactions were successful, one transaction failed. The funds were deducted twice (please attach declined slip if available)
The customer used the card but the transaction was unsuccessful. The funds were deducted. The customer used other means of payment. (please attach declined slip if available)
Cash/Funds not received from the ATM : full amount (please attached declined slip if available)
Cash/Funds not received from the ATM : partial amount received (please attached declined slip if available)
Goods/Services were not received (please attach declined slip if available)
Select an option
Did you cancel the order prior to the delivery date of the goods/service? (Online)
*
yes
no
Select an option
Did you try to resolve the dispute with the merchant?
*
yes
no
Select an option
If YES, when did you attempt and why did the merchant fail to resolve the dispute?
You must fill the value
If NO, what are the reasons ?
You must fill the value
Please attach here the files requested above (PDF)
PDF, PNG, JPEG, JPG
You must fill the value
Other file
PDF, PNG, JPEG, JPG
You must fill the value
I confirm that:
*
I did not authorise any person to effect the said transaction(s) on my behalf.
I received no benefit from the proceeds of the said transaction(s).
I am aware that your issuing bank, will be taking action based on the contents of this statement.
This statement is accurate and complete.
I am also aware that investigations of disputed card transactions take up to 45 business days to complete.
Select an option
Annex A
List below multiple Fraud transactions, only 35 are allowed per card:
Transaction or Settlement Date
*
You must fill the value
Merchant Name
*
You must fill the value
Transaction Amount
*
You must fill the value
Disputed Amount
Please input the disputed amount
Please indicate the number of disputed transactions
*
1 times
2 times
3 times
4 times
5 times
more than 5 times
Select an option
Claim, loss or damages
*
I hereby indemnify you, your employees or agents against any claim, loss or damages, both direct and indirect, which may arise as a result of actions taken based on the information provided in this statement.
Select an option