Numi Financial Dispute Form

Numi Financial
Cardholder Dispute Form

This form has been provided for your convenience. If you believe that a transaction/s on your account is in error you can
use this form to dispute the transaction/s in question.
Please complete and mail or fax a copy of this form along with any supporting documentation to Card Services, ATTN:
Dispute Dept., PO Box 543000 Omaha, NE 68154, or Fax to 917-979-2032.
PLEASE DO NOT ALTER THE WORDING ON THIS FORM
Personal Information (Please fill this section out completely. Failure to do so will result in a delay of your claim
resolution)
George christou
Your Name: _____________________________ 5285170140288750
Account Number: ________________________
(16 Digit Card Number)
5093705362
Telephone: ______________________________Best 2pm-8pm
time to call: _________________________
1475 venetian dr sw
Address Line 1: __________________________________________________________________
Address Line 2: __________________________________________________________________
Atlanta
City: ______________________________
State: ______________________________
Georgia
30311
Zip Code: __________________________
[email protected]
Email Address (optional): _______________________________________________
Transaction Information (please refer to your statement for assistance)

Transaction Date: _______________________
06/27/2024 06/27/2025
Posting Date: ___________________
Amount $: _____________________________Disputed
$200.00 $200.00
Amount $:______________
Atm link
Merchant Name: ________________________Reference Number: ______________
4183 sequence number
Disputing more than one item? Yes ___ No X
____
Select Type of Dispute (Check only one)
⧠ Charged twice for the same transaction – I certify that the charge in question was a single transaction, but was
charged twice to my account. I did not authorize the second transaction.
Sale # 1 (Valid Transaction) $________________ Reference #: ______________

Sale # 2 (Invalid Transaction) $________________ Reference #: ______________
⧠ Cancellation (hotel, good, services, ..) – Please enclose copy of letter, email, or fax informing the merchant of
cancellation.
Date of cancellation ________________ Cancellation # _________________________
Reason for cancellation? __________________________________________________
⧠ Merchandise was returned - Please attach signed copy of proof of return.

Reason for returning ______________________________________________________
If you are unable to return the merchandise, please explain

________________________________________________________________________
⧠ Merchandise not received - Please notify the merchant of non-receipt.
I have not received merchandise that was to be shipped or picked up on (mm/dd/yy) ____/____/____
I have asked the merchant to credit my account No ____ Yes ____
If Yes, when? ____/____/____
⧠ Merchandise shipped was either damaged or defective - You must explain in detail how the merchandise was
damaged or defective, provide proof and attempt to return the merchandise prior to exercising this right.
I have asked the merchant for a credit to my account No ____ Yes ____
If Yes, when? ____/____/____
⧠ Overcharged for a transaction - Please include a copy of the signed sales receipt.
The amount was increased from $ _____ to $ _____
⧠ Credit posted as a sale - Please attach a copy of the credit slip and the original sales slip.
⧠ Credit not posted to account - Please enclose a copy of the credit slip or notice of credit from the merchant
and a detailed explanation of your dispute. The merchant has 30 days to credit your account.
⧠ Transaction paid by other means - You must provide proof of paid by other means such as a copy of
the cancelled check (front and back), a cash receipt, or a statement from another credit/debit card account.
⧠ ATM (Partial dispensed)

I made attempt/s and did not get the full amount
Amount Charged: __________ Amount Dispensed: __________
⧠ ATM (Non dispensed)

$200.00
Requested amount __________
⧠ Unauthorized charge - I certify that I did not authorize or participate in this transaction with the above-mentioned
merchant, nor did I authorize anyone else to use my card. To use this option, you must report your card
lost or stolen immediately.
Please provide additional details:
1. Date card was lost or stolen ________________________
2. Where do you store your PIN? ______________________
If you are disputing more than one transaction please use the space below:
DATE AMOUNT DESCRIPTION (Merchant Name) REFERENCE NUMBER
⧠ Other - Please enclose a DETAILED description on a SEPARATE SHEET and attach it to this form.
SIGNATURE REQUIRED _________________________________ 06/30/2024

DATE_____________
Please keep the original for your records

Numi Financial Dispute Form

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Numi Financial Dispute Form

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Numi Financial

Cardholder Dispute Form

PLEASE DO NOT ALTER THE WORDING ON THIS FORM

Transaction Information (please refer to your statement for assistance)

Select Type of Dispute (Check only one)

Sale # 1 (Valid Transaction) $__ Reference #:

⧠ Merchandise was returned - Please attach signed copy of proof of return.

If you are unable to return the merchandise, please explain

⧠ Merchandise not received - Please notify the merchant of non-receipt.

⧠ ATM (Partial dispensed)

⧠ ATM (Non dispensed)

DATE AMOUNT DESCRIPTION (Merchant Name) REFERENCE NUMBER

SIGNATURE REQUIRED _________________________________ 06/30/2024

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