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Dispute Resolution Form

The document is a Dispute Resolution Form for a chargeback related to a transaction with the merchant Brilliant Moyo, dated April 29, 2023, for an amount of 20 USD. It includes sections for cardholder dispute details, types of disputes, and cardholder participation, along with a certification of compliance with Mastercard standards. The form requires signatures from both the chargeback representative and the cardholder to confirm the accuracy of the information provided.

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ashelym440
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25 views

Dispute Resolution Form

The document is a Dispute Resolution Form for a chargeback related to a transaction with the merchant Brilliant Moyo, dated April 29, 2023, for an amount of 20 USD. It includes sections for cardholder dispute details, types of disputes, and cardholder participation, along with a certification of compliance with Mastercard standards. The form requires signatures from both the chargeback representative and the cardholder to confirm the accuracy of the information provided.

Uploaded by

ashelym440
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Dispute Resolution Form Chargeback Reference:____________

Transaction Information:
Acquirer’s Reference Data or Switch Serial Number: 0785981838
Merchant Name: Brilliant Moyo

Transaction Amount:
Transaction or Settlement Date: 29
20usd
April2023
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
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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 Date
Signature

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