CARDHOLDER STATEMENT OF DISPUTE
Claim #
Cardholder’s name:
Client ID:
Card Number:
I have examined the charges made to my account and I dispute the transactions indicated on this page.
(The account statement with transactions claimed marked should be added to this form if customer claimed more than three transactions).
Transaction Date Merchant Name Amount
Check the box that better describes your dispute:
I DO NOT RECOGNIZE THIS TRANSACTION, it has not been made by me or anyone authorized to use my card.
CHARGED MORE THAN ONCE, I authorized the transaction once but was charged two or more times
CASH NOT DISPENSED FROM ATM, I requested ___________________, but received ____________________
I PAID THIS TRANSACTION BY OTHER MEANS. (Please provide evidence of payment)
MERCHANT AGREED TO CREDIT MY ACCOUNT, 30 days have passed and I still have no credit. (Please provide evidence)
I DID NOT RECEIVE THE MERCHANDISE OR SERVICES, more information included bellow. (Please provide evidence and date)
I CANCELLED THIS TRANSACTION BEFORE IT WAS CHARGED. (Please provide evidence of cancellation and date)
INCORRECT AMOUNT, I authorized a transaction for ______________, but the charged amount is ________________.
(Voucher attached)
PAYMENT WAS NOT APPLIED TO THE MERCHANT, but it is displayed in my account statement. (Please provide evidence)
Had this card been Lost/Stolen? YES NO
Additional Info: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Bank’s Representative:
I certify that the facts obtained from the interaction with the client or his representative are accurate.
Date: Time:
A service fee will be charged if the claim does not proceed. Check the published tariff for rates.
Estimated response time is 60 days. For additional information please call TeleScotia.
This claim does not suspend payment obligations and is valid for regulatory purposes.
