Dispute Form

Full names *

Identify number *

Contact number *

Email adress *

Card number / virtual number for online transactions *

Date of disputed transaction *

Amount *

Transaction Type ATM/POS/Online *

Country of dispute *

Merchant / ATM name *

Description of what happened ? *

Description of goods / services purchased ? (for Online/POS)

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)

Did you cancel the order prior to the delivery date of the goods/service? (Online) *

yes

no

Did you try to resolve the dispute with the merchant? *

yes

no

If YES, when did you attempt and why did the merchant fail to resolve the dispute?

If NO, what are the reasons ?

Please attach here the files requested above (PDF)

PDF, PNG, JPEG, JPG

Other file

PDF, PNG, JPEG, JPG

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.

Annex A

List below multiple Fraud transactions, only 35 are allowed per card:

Transaction or Settlement Date *

Merchant Name *

Transaction Amount *

Disputed Amount

Please indicate the number of disputed transactions *

1 times

2 times

3 times

4 times

5 times

more than 5 times

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.

Bienvenue

Identify yourself

Dispute Form

Bienvenue

Identify yourself

Dispute Form

Data protection