Please contact us at 1-800-727-5626 or 305-577-1328 before submitting this form
Print Application!

Date:
Cardholder's Name:
Card Number:
Transaction Amount	Transaction Date	Merchant	Transaction Amount	Transaction Date	Merchant
1.			6.
2.			7.
3.			8.
4.			9.
5.			10.

	1.	The amount of the charge was increased from $_______________ to $_______________ or my sales slip was added incorrectly. Attached is my copy of the sales draft that shows the correct amount.
	2.	I certify that the charge listed above was not made by me or a person authorized by me to use my card, nor were the goods or services represented by the transaction received by me or a person authorized by me. (If you do not recognize a sale, choose this option.)
	3.	I have not received the merchandise that was shipped to me on _______________ (date). I have asked the merchant to credit my account.
	4.	The attached credit slip was listed as a charge on my account.
	5.	I was issued a credit slip that was not shown on my statement. A copy of my credit slip is enclosed.
	6.	Although I did engage in the above transaction, I dispute the entire charge or a portion in the amount of $_______________. I have contacted the merchant and requested a credit adjustment. I either did not receive this credit or it was unsatisfactory. I am disputing the charge because: _______________________________________________________________________________________ _______________________________________________________________________________________
	7.	I certify that the charge in question was a single transaction, but was posted twice to my statement. I did not authorize the second transaction. Sale #1 $_______________ Reference # ____________________________________ Sale #2 $_______________ Reference # ____________________________________
	8.	I notified the merchant on _______________ (date) to cancel the preauthorized order (reservation). Please note cancellation # and if available, attach a copy of your telephone bill showing the date and time of cancellation. Reason for cancellation: ________________________________________________________ _______________________________________________________________________________________
	9.	Although I did engage in a transaction with the merchant, I was billed for transactions totaling $_______________ that I did not engage in, nor was anyone else authorized to use my card. I do have all my cards in my possession. Attached is a copy of my sales slip for the valid charge.
	10.	Merchandise that was shipped to me has arrived damaged and/or defective. I returned it on _______________ (date) and asked the merchant to credit my account.
	11.	I have returned merchandise on _______________ (date) because: _______________________________________________________________________________________ _______________________________________________________________________________________
	12.	Other. Please explain. _______________________________________________________________________________________ _______________________________________________________________________________________

Please check only one box, do not alter the wording on this form, and provide copies of all documentation that will help us investigate your dispute (i.e. contracts, invoices, detailed letter, sales draft).

Signature (Required)

Date:

Office Use Only:

Financial Institution:

Contact: