Submit a Debit Card Dispute

Use this form to submit a claim for any charges on a card that the cardholder would like to dispute.

Your Information

Contact Name Email

Merchant Information

Please use this form for "errors" as defined under Regulation E (1005.11(a)). If the dispute does not qualify as an "error", per this definition, you must make every effort to resolve the dispute with the merchant Merchant Name Amount Cardholder Contact Date Transaction ID

Dispute Details

Type of Dispute

Cardholder did not authorize or participate in this transaction(s).
Card was Did user provide their card details

Cardholder must contact the merchant prior to disputing the charge, and must provide proof of cancellation within the free trial period.

Cardholder must attempt to contact the merchant prior to disputing this charge.

Item(s) Ordered. Include Detailed Description of Merchandise/Services (items purchased - must include product, sizes, colors, brand, etc)

Date merchandise/service was expected or received

Cardholder must attempt to contact the merchant prior to disputing the charge. Only one transaction is valid but posted more than once. All cards issued to the cardholder are in their possession.

Valid transaction amount
Valid transaction post date

Invalid transaction amount
Invalid transaction post date

Method of enrollment
Free trial enrollment date
Free trial offer was good through

Merchant was notified on
Reason for cancellation
Name of shipping company, as applicable
Invoice/tracking number, as applicable
Date the Merchant received the merchandise, as applicable
Disposition of the merchandise, as applicable
Did the merchant refuse the return of merchandise, refused to provide a return merchandise authorization, or informed the Cardholder not to return the merchandise?

Cardholder must attempt to return the merchandise prior to exercising this right. Please attach signed proof of return, credit slip or postal receipt to your reply email.
Reason for return
Merchandise was received

Merchandise was returned

Tracking number for return

Cancellation date
Cancellation number

Was the cardholder advised of a cancellation policy?

Purchase Order

Location for delivery/pickup
Expected delivery date

Specify why the merchandise/service were not as described – provide a detailed description
Who has possession of this merchandise?
Was an attempt made to return the merchandise?

Shipping/Tracking Details

You must attempt to contact the merchant prior to disputing the charge.

Merchant was contacted on

What was the outcome from contacting the merchant?

Merchant Contact Name

Method used to contact merchant

Merchant response

Amount requested
Amount received

Please check your email inbox for a confirmation message. Please respond directly to that message with any relevant attachments.

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