Fillable Printable Credit Card Dispute Form - Citizens Bank
Fillable Printable Credit Card Dispute Form - Citizens Bank
Credit Card Dispute Form - Citizens Bank
Credit Card Dispute Form
Thank you for your recent inquiry regarding a charge on your account. The Fair Credit Billing Act requires written notification to
us of a dispute no later than 60 days after receipt of the billing statement on which the charge appeared. The following
information is required to initiate your dispute:
Transaction Date: Amount $: Merchant Name:
Your Daytime Phone #: or E-mail:
Credit Card Account #:
Prior to submitting this form, you must try to resolve the issue directly with the merchant.
On a separate piece of paper, provide details on how you tried to resolve this with the merchant.
Select ONE statement that is the most accurate account of your dispute.
1 I have NOT authorized this charge to my account. I certify that the charge was not made by me or any person
authorized by me to use my credit card. No goods or services have been received.
2 I have been billed more than once by the same merchant. I authorized one transaction for $ .
I certify my card was in my possession at the time of the transaction. Date of duplicate charge .
The person who authorized the transaction must sign this form.
3 I was billed the wrong amount. The correct amount is $ . Attach evidence to support your claim.
4 The service or merchandise I received was not as described. Describe the service or merchandise you were to
receive, and how it differed from what you ordered or contracted for. Attach documentation (i.e. copies of sales
slips, emails, contracts) to support your claim.
5 I returned the merchandise on . Attach proof of return.
Explain why you returned the merchandise (i.e. defective):
6 I cancelled the service on . Provide evidence of cancellation.
7 I did NOT receive the service I contracted for with the merchant. Describe service you did not receive.
8 I did NOT receive the merchandise. Expected Delivery Date .
9 Other. Attach a detailed letter and supporting documents as to why you are disputing the charge.
I certify that I have provided the required information and it is accurate to the best of my knowledge.
Signature ______________________________________________ (Required) Date
Please complete this form immediately, as the dispute process starts upon receipt of this form. Return to
Credit Card, P.O. Box 7092, Bridgeport CT. 06604-7092. Or Fax to 1-888-727-0028.
If you have questions, contact any Chargeback Analyst at 1-877-945-4060. M-F 8:30 a.m. to 5:00 p.m. EST.
DE-CB-RUSMCB013/REFNUM V1 JAN 2010
