CUSTOMER CARD DISPUTE FORM
Name:*
CPR / ID No:*
Card No#:*
Phone#*
Email:
Dispute Amount:*
Dispute Amount in BHD:*
Merchant Name:*
Transaction Date:* DD/MM/YYYY
Processing Date: DD/MM/YYYY
 
I have examined the charges made to my account and I am disputing the above item for one of the following reasons
(Please select minimum 1 reason)
SL     Please select reason below
1 I did not authorize this charge nor did I participate in the transactions. 'Subject to BD 5.000 Fee'.
2 Sales receipt amount was increased from to .
3 The charge in question was a single transaction (sale #1) but was billed twice to my statement.I did not authorize the second transaction.
4 I am not disputing this charge; however, I need a copy for my records. 'Subject to BD 5.000 Fee'.
5 I did participate in the transaction, However, I paid for the trasaction using another form of payment

(Describe the other form of payment)

Enclosed is a copy of my other form of payment (i.e. other card statement, and cash receipt etc).
6
I did not receive from an ATM located at

I have received part of cash only, I requested for I have received only

I have not participated on the above ATM cash transaction.
7 I have not received the merchandise. The expeceted delivery date was (DD/MM/YY)

I contacted the merchant (DD/MM/YY) and requested that my account be credited

I spoke with (name).
8 I notified the Hotel on (DD/MM/YY) at (am /pm) to cancel the pre-authorized order/reservation.

Cancellation # (required). Enclosed is documentation showing proof of return or cancellation.
9 I was issued a credit for on (DD/MM/YY), which has not been posted to my account

I have enclosed a copy of my credit proof (credit slip, refund voucher, email confirmation etc).
10 Other, please explain:
Attachment if any (Maximum 3 MB)
I declare that the information started in this form is true and correct to the best of my knowledge.
Please print and fax a copy of this form to 17214193 with your signature
Fields Marked * are compulsory