Get 5161 Template 2019-2024

MASTERCARD CARDHOLDER DISPUTE NOTIFICATION Please provide the required information or documentation that may be helpful in resolving the dispute or else your claim may be initially denied. We may need to contact you for additional information so make sure that your contact information is current. Only one disputed transaction per form. Each disputed transaction requires its own form to be completed. Thank you. IMPACTED DEBIT CARD NUMBER 16-digits CARDHOLDER NAME CARDHOLDER PHONE NUMBER BECU USE ONLY Person EMAIL ADDRESS MERCHANT NAME AMOUNT POSTED TO ACCOUNT AMOUNT DISPUTED if amount is different from the amount posted POST DATE Disputing more than one item Yes No If Yes then this is number of e.g. 1 of 3 Only one transaction per form SIGNATURE REQUIRED DATE For all Disputes Date merchant was contacted to attempt to resolve Merchant s response If this was for a hotel room did you request a reservation If Yes this is not an unauthorized charge. IMPACTED DEBIT CARD NUMBER 16-digits CARDHOLDER NAME CARDHOLDER PHONE NUMBER BECU USE ONLY Person EMAIL ADDRESS MERCHANT NAME AMOUNT POSTED TO ACCOUNT AMOUNT DISPUTED if amount is different from the amount posted POST DATE Disputing more than one item Yes No If Yes then this is number of e.g. 1 of 3 Only one transaction per form SIGNATURE REQUIRED DATE For all Disputes Date merchant was contacted to attempt to resolve Merchant s response If this was for a hotel room did you request a reservation If Yes this is not an unauthorized charge. You must call the merchant and attempt to resolve the dispute. If you received a cancellation number for a reservation please see the dispute reasons listed below. Select Type of Dispute check only one Duplicate charge. Cardholder certifies one transaction is valid but posted more than once. The card indicated at the top of this form is in my possession. Valid Transaction Post Date Invalid Transaction Cancellation. Please enclose Copy of letter email or fax informing the merchant of cancellation. Reason for cancellation Were you advised of a cancellation policy If Yes what were you told Trial membership. Did you follow the merchant s cancellation Were you required to return any products RMA Number return merchandise authorization Proof of return Provide copy of receipt or tracking number BECU 5161 03/2018 Did you receive any product s Did you return any product s Returned merchandise. MASTERCARD CARDHOLDER DISPUTE NOTIFICATION Please provide the required information or documentation that may be helpful in resolving the dispute or else your claim may be initially denied* We may need to contact you for additional information so make sure that your contact information is current. Only one disputed transaction per form* Each disputed transaction requires its own form to be completed* Thank you. IMPACTED DEBIT CARD NUMBER 16-digits CARDHOLDER NAME CARDHOLDER PHONE NUMBER BECU USE ONLY Person EMAIL ADDRESS MERCHANT NAME AMOUNT POSTED TO ACCOUNT AMOUNT DISPUTED if amount is different from the amount posted POST DATE Disputing more than one item Yes No If Yes then this is number of e*g* 1 of 3 Only one transaction per form SIGNATURE REQUIRED DATE For all Disputes Date merchant was contacted to attempt to resolve Merchant s response If this was for a hotel room did you request a reservation If Yes this is not an unauthorized charge.