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Transaction Dispute Form

The document is a card dispute form submitted by a customer, Raviteja Dhammishetty, to ICICI Bank disputing a charge of Rs. 3899.08 from Google Ads shown on their credit card statement dated 04-02-2022. The customer claims they did not authorize or incur the transaction. They have signed the form declaring the information is true and their card was in their possession at the time. The form also lists the documents required from the customer for the bank to investigate the disputed transaction based on the card and transaction type.

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Raviteja Dhammishetty
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© © All Rights Reserved
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2K views

Transaction Dispute Form

The document is a card dispute form submitted by a customer, Raviteja Dhammishetty, to ICICI Bank disputing a charge of Rs. 3899.08 from Google Ads shown on their credit card statement dated 04-02-2022. The customer claims they did not authorize or incur the transaction. They have signed the form declaring the information is true and their card was in their possession at the time. The form also lists the documents required from the customer for the bank to investigate the disputed transaction based on the card and transaction type.

Uploaded by

Raviteja Dhammishetty
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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To,

The Manager Operations


ICICI Bank Limited
ICICI Bank Tower, C – Wing
Autumn Estate, Near Chandivali Studio
Chandivali Farm Road,
Opp. Mhada Colony, Chandivali
Andheri (East), Mumbai 400072 Date: _____________
04-02-2022

CardMember Dispute Form

CARD NUMBER 4 0 0 7 8 2 0 9 2 1 0 0 0 5 3 1
DETAILS OF DISPUTED ITEM Charge details shown in my statement dated __________________

TRANSACTION MERCHANT TRANSACTION DISPUTED


DATE NAME AMOUNT AMOUNT
02-02-2022 GOOGLE ADS 3899.08 3899.08

I am disputing the transaction(s) listed above for the reason as follows and request you to settle the cases
 I have neither incurred nor authorised the above transactions
 I have been charged twice for the same transaction
 I have incurred one transaction dated ____________ at the above merchant establishment. However, I have not
incurred or authorised the transactions listed above.
Attached is my copy of chargeslip for the genuine transaction.
 The transaction amount incurred was ___________, but I have been billed for _________
Attached is my copy of chargeslip showing the actual amount.
 I have never received the ordered merchandise whose delivery date was _________
Attached is a copy of my letter to the merchant attempting to resolve the dispute.
 My hotel reservation was cancelled on __________. However I have been billed a No-Show Charge. The cancellation
number is ____________.
 I already paid the transaction amount by other means and the evidence is enclosed.
Paid by Cash/ Cheque/ DD/ Credit Card #___________________________________ dated _______________
Enclosed is a copy of my Cash Memo/ Bank Statement/ Payment Counterfoil/ Card Statement.
 The credit voucher was issued on _______________ but not processed to my account.
Attached is a copy of my Credit/ Refund Slip/ Cancellation letter from merchant establishment.
 ATM Transaction attempted by me did not dispense cash for Rs.___________
 ATM Transaction attempted by me partially dispensed cash for Rs. ____________
Attached is my copy of ATM slip.
 Others ( any additional comments)
__________________________________________________________________________________________________________
______________________________________________________________________________________________________
DECLARATION
I hereby affirm that the information furnished above is true to the best of my knowledge.
My card was in my possession and control at the time of the questioned transactions.
Name: ____________________________________________
DHAMMISHETTY RAVITEJA
Phone/ Fax: ______________________________________
Date: _____________________________________________
04-02-2022 Cardholder’s Signature

Mandatory: FOR RESOLUTION OF THE DISPUTE, PLEASE FORWARD THE DULY SIGNED AND FILLED CDF ALONG
WITH THE APPLICABLE DOCUMENTS MENTIONED ON PAGE NO. 2
1
List of Documents

To initiate investigation for the disputed transaction, the Cardholder needs to submit a copy of the below
mentioned documents.

Type of
Type of Card Documents Required
transaction

 Duly filled Customer Dispute Form (CDF). CDF to be signed by the Card
Holder of the card for which dispute is being raised.
 Copy of face of the Card on which dispute is being raised
Copy of any one Photo ID proof mentioned below (Please carry the original
Debit Card/ document for verification): Domestic &
Credit Card  Passport International
 PAN Card
 Voter ID Card
 Driving licence
 Government ID Card
 Photo Ration Card
 Senior Citizen ID Card

To establish proof of presence, please provide the following documents. In case of Joint Account/transaction is
done using Add-on Credit Card, the proof of presence will be required for all holders

Type of
Type of Card Documents Required
transaction

1. If the cardholder was in the same location where disputed transaction took
place, please provide any of the below mentioned proof which substantiates
the claim.
 HR letter confirmation, if the cardholder was present in office on the date of
disputed transactions. HR letter should be on Company letter head duly signed
and stamped Domestic &
 Statement of usage of any other bank card on date of disputed transactions International
Debit Card/ confirming cardholder’s availability in that particular place and city
Credit Card  Hotel stay proof on date of disputed transactions confirming presence in that
particular place and city
 Itemised postpaid mobile bill of the cardholder for the period when disputed
transaction has taken place

2. If cardholder was not present in the country where the disputed transactions International
took place,
 Please provide a copy of all the pages of the passport.
Debit Card/ Domestic &
 Police Complaint copy, if lodged
Credit Card International

Cardholder’s Signature

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