Disputed Transaction Form

Transaction Dispute Form
Please complete all sections of the Transaction Dispute Form (as applicable).
If you have not done so already, you may also call us (see the back of your card OR the ‘Contact Us’ section on our website for our Customer
Support phone number) during business hours to file your dispute directly with us. (This form may still be requested by your customer service
representative.)
Please provide all relevant information about your dispute, including all information you may have previously provided to a customer service
representative, if applicable.
Please note, you must wait for a pending transaction to post before a dispute can be filed.
Card Details
Card Number Case Number
(Last 4 numbers on the front of your card) (A customer service representative may have verbally provided this to you when
you filed your dispute. If you did not call, please write "N/A" in this section.)
1351 113781198
Disputed Transactions
Please list all transactions you wish to dispute. If you need to list additional transactions, please include an additional page.
Date Merchant name Amount

12/16/2022 PAYPAL *TRANCAMVAN $ $20.0
$
$
$
Reason for Dispute

Please check the box(es) most appropriate and attach any corresponding documentation (if applicable).
I authorized and participated in the transaction(s) provided but have the following issue:
Duplicate transaction Credit not received
Expected refund amount $

Processed for the incorrect amount
Expected refund date
Amount expected to pay $
Amount charged $
I have not received the goods or services I paid for.
Paid by other means They were expected on:
By what other means did you pay?
(e.g. in cash, 1/2 on another card, etc.) Date
I attempted to withdraw cash from an ATM:

I have contacted the Merchant to try to resolve this
matter. My last contact was on: Amount requested $
Date Amount received $
NOTE: Please include copies of any of the following: proof of credit/refund receipt, email, letter, sales receipt ATM receipt, proof that the
goods were returned, services were cancelled, or an attempt was made in addition to any details of the merchant’s response (as applicable).
I have not authorized nor participated in the transaction(s) listed above and:
Please note that if the above transactions are identified as fraudulent, and your card/account has not yet been secured, it may require the
cancellation of your card and issuance of a new one.
I have never done business with this merchant. I have done business with this merchant in the past, but I
did not authorize the above transaction(s).
For transactions reported as not authorized, please confirm the following:
✔ I have my Card in Possession
Where do you keep a record of your PIN?
(memorized, written down, all details are helpful.) My Pin is in my head
Has your PIN been shared with anyone else?

(including family members) Yes No
Has your account login information been shared

Yes No
with anyone else?
If Yes, please provide details
My Card was Lost/Stolen

Date and time loss/theft occurred: Date Time
Was your PIN lost/stolen as well?

If Yes, please provide any details below Yes No
Describe how and when you became aware of loss or theft

(please provide as many details as possible, e.g., scenario which loss or theft occurred etc., details will assist us in the investigation process).
I was sitting in my car and i received a notification saying, the amount of $20 has been debited from my account
By PAYPAL
Police Report Details (if applicable)

What date and time did you report to the police? Date Time
Police report number Police officer’s name
Contact number Station/Location
Additional Information
Please provide any additional information that may be helpful in assisting with your dispute.
MARILYN BURGY
ACCOUNT NUMBER 9945 9430 8569
Signature
I certify that my statements in this dispute form are true, complete, and correct to the best of my knowledge and belief. I
understand that all statements made regarding this dispute may be investigated.
MarilynBurgy MARILYN BURGY 12/21/2022

Signature Printed Name Date
Please return this completed form and any supporting documents to: Attention: Disputes, PO Box 9 West Chester, OH 45071

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Transaction Dispute Form

Date Merchant name Amount

Reason for Dispute

Duplicate transaction Credit not received

Expected refund amount $

I attempted to withdraw cash from an ATM:

Date Amount received $

Has your PIN been shared with anyone else?

Has your account login information been shared

If Yes, please provide details

My Card was Lost/Stolen

Was your PIN lost/stolen as well?

Describe how and when you became aware of loss or theft

Police Report Details (if applicable)

Police report number Police officer’s name

Contact number Station/Location

ACCOUNT NUMBER 9945 9430 8569

MarilynBurgy MARILYN BURGY 12/21/2022

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