Transaction Dispute Form copy

Dubai First Transaction Dispute Form
Card Number
Merchant Name
Transaction Date
Transaction Amount
I hereby dispute the above mentioned for the following reason (Please check relevant box)
Neither did I participate nor did I authorize the transaction. My card was in my possession at the time of the transaction.
I did not authorize the above Internet / Phone / Mail Order transaction.
I have been debited twice / more than twice.
I cancelled the transaction in writing / phone (dd/mm/yy)
and the cancellation number is
I returned the goods on (dd/mm/yy)
The refund / credit has not been processed to my account.
The refund / credit has been posted as a debit to my account.
I paid for the transaction by other means
Cash
Cheque
Others.
I did not receive the goods / service which was expected by (dd/mm/yy)
The amount of the charge was for
and not
Enclosed is the copy of the charge slip, which shows the correct amount.
I certify that the ATM transaction was not completed (Cash was not dispensed / dispensed partially)
but transaction amount has been billed to my account.
Other (Please specify)
• Please attach relevant documents to support the dispute, without which the dispute will not be processed.
• Disputes should reach within 14 days of the statement date else transaction will be treated as correct.
• I understand and authorize Dubai First to debit my credit card with a fee of AED 25.00 for the retrieval of the Sales Draft,
if the merchant proves the disputed transaction to be valid.
Primary / Supplementary Cardholder Name :
Phone
:
Mobile :
Fax :
I hereby certify that the information furnished above is true to the best of my knowledge.
Please fax this application to 04 - 506 8422
Date :
Terms & conditions apply.
Feb 09
Customer’s signature :