Directions: Completely fill out and submit this form. If you prefer fax or email a PDF version of this form, click here to Download/Print a PDF.
Disputes must be filed within 90 days of the transaction posting.
Transactions to DisputeYou may dispute up to 3 transactions on this form.
Please complete the section below that best describes the reason for submitting this claim.• If FRAUD, please fill out a reason from the “Fraud Reasons” section. • Or, if this is a MERCHANT DISPUTE, please fill out a reason from the “Dispute Reasons” section. You may be contacted by the institution to obtain additional information. Failure to respond may result in your claim being denied.
DISPUTE REASONS: Before disputing charges, please make every effort to resolve with the merchant.
––––––––––––––––––––––––––––––