Scribd
Upload
9 views

Dispute Resolution Form BLANK

The document is a Dispute Resolution Form for chargebacks, requiring detailed transaction and cardholder information. It includes two sections for the cardholder to specify the nature of the dispute and a section for detailed complaint description. The issuer certifies compliance with Mastercard standards and privacy laws, and both the chargeback representative and cardholder must sign and date the form.

Uploaded by

Ma Zhet
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
9 views

Dispute Resolution Form BLANK

The document is a Dispute Resolution Form for chargebacks, requiring detailed transaction and cardholder information. It includes two sections for the cardholder to specify the nature of the dispute and a section for detailed complaint description. The issuer certifies compliance with Mastercard standards and privacy laws, and both the chargeback representative and cardholder must sign and date the form.

Uploaded by

Ma Zhet
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Dispute Resolution Form Chargeback Reference:____________

Transaction Information:
Acquirer’s Reference Data or Switch Serial Number:
Merchant Name: Transaction or Settlement Date:
Transaction Amount: Disputed Amount:

Cardholder details:
Cardholder full name: Identity number:
Contact number: Email address:
Wallet ID: Card Number:

Complete Section A or Section B as applicable and Section C:

Section A
Cardholder Dispute Chargeback

Type of Cardholder Dispute (check one):


Goods or services were not as described or defective, includes shipped merchandise received
damaged or not suitable for its intended purpose or merchant didn’t honor the terms and conditions
of a contract.
Delivery date of the goods or services:
Goods or services were not provided
Expected delivery date of the goods or services:
Digital goods were purchased totaling USD 25.00 or less and did not have adequate purchase
controls
Credit not processed
Return or cancellation date:
Counterfeit goods alleged to be authentic were purchased
Recurring transaction cancelled prior to billing
Cancellation date:
Recurring agreement was not properly disclosed
Addendum dispute
“No-Show” hotel charge was billed
Purchase transaction did not complete
Timeshare agreement or similar service provision was cancelled within Mastercard time frame
Credit posted as a purchase

Cardholder Participation:
Did the cardholder participate in the transaction? Yes No

1|Page of 3
Section B
Point of Interaction (POI)

Type of Point of Interaction (POI) Error (check one):

The cardholder was debited more than once for the same goods or services.
Alternate means of payment details:

The cardholder was debited an incorrect amount.

The cardholder was billed for loss, theft, or damage in the same transaction as the underlying initial
service.

The cardholder states that he or she was not given the opportunity to choose the desired currency
in which the transaction was completed or did not agree to the currency of the transaction.

The merchant processed a credit (instead of a reversal) to correct an error which resulted in the
cardholder experiencing a currency exchange loss.

Section C
Dispute Details
Describe the cardholder’s compliant in sufficient detail to meet the requirements for the chargeback as
described in the Chargeback Guide and to enable all parties to understand the dispute

Mastercard will determine whether this information contains sufficient detail.

“The issuer certifies that it complies with Mastercard Bylaws, Rules, policies and operating regulations and
procedures of Mastercard (the “Standards”), written agreements and privacy laws and regulations applying to the
protection of personal data. The issuer agrees that the personal data collected may be used according to Mastercard
Standards and Mastercard’s Global Privacy Notice on http://www.mastercard.us/privacy/. I certify that the facts were
obtained from my discussion with the cardholder or the company/government agency representative on behalf of the
corporate/government card cardholder and that the facts are accurate to the best of my knowledge.”

Customer Service/Chargeback Representative Date

I certify that the information herein is accurate and complete. I hereby indemnify you, your employees or agents against any claim,
loss or damages both direct and indirect, which may arise as a result of actions taken based on the information provided in this
Dispute Form.

Cardholder Signature Date

2|Page of 3

You might also like