Transactions to Dispute
You 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.
FRAUD REASONS: Please note that in all cases of FRAUD, card will be closed immediately, and a new card will be issued.
DISPUTE REASONS: Before disputing charges, please make every effort to resolve with the merchant.