Transaction Dispute Form / Written Statement of Unauthorized Debit
Please complete and print this form if you are disputing a charge from a merchant that has posted to your
account. Please include a copy of all supporting documentation such as transaction receipts and
correspondence with the merchant. Please mail all forms and any additional information in one envelope
to: Green Dot Corp. Transaction Dispute, P.O. Box 5100, Pasadena, CA 91117-0100
Section A – Cardholder Information
Please provide all the following pieces of information and sign the form where indicated:
Cardholder’s Name: Cherie Wallace
2nd Cardholder’s Name (if applicable):
Last 4 Digits of Card Number: Preferred Phone: ( 229 ) 269 - 6280
Mailing Address: 543 GA Highway 159 Pitts, GA 31072 New mailing address
E-mail: moncherie126@gmail.com New email address
Section B – Transaction Information
Please provide all the following information regarding the transaction(s) being disputed.
Please complete and print additional forms if you are disputing more than five transactions.
Transaction # 1: Transaction Amount: $ . Date of Transaction: / /
Merchant’s Name:
Transaction # 2: Transaction Amount: $ . Date of Transaction: / /
Merchant’s Name:
Transaction # 3: Transaction Amount: $ . Date of Transaction: / /
Merchant’s Name:
Transaction # 4: Transaction Amount: $ . Date of Transaction: / /
Merchant’s Name:
Transaction # 5: Transaction Amount: $ . Date of Transaction: / /
Merchant’s Name:
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Transaction Dispute Form / Written Statement of Unauthorized Debit
Section C – Dispute Reason
Please read each of the following descriptions carefully and enter the number of the disputed
transaction(s) from Section B in the box that pertains to the reason you are disputing that
transaction.
Transaction
number(s)
from Section B: Dispute Reason:
I have not authorized this charge to my card. I have not purchased or ordered merchandise in
person, by phone, or by mail, nor have I received any goods or services from this merchant.
▪ My card was noticed missing/lost/compromised on / / .
▪ Did anyone else have access to your card or PIN? Yes No
If yes, please explain how:
For ACH debits: I (the undersigned) hereby attest that (i) I have reviewed the circumstances of
the above electronic (ACH) debit to my account, (ii) the debit was not authorized, and (iii) the
following, to the best of my ability to identify, is the reason for that conclusion:
I revoked the authorization I had given to the party to debit my account before the debit was
initiated.
My account was debited before the date I authorized.
My account was debited for an amount different than I authorized.
My card has been charged for the transaction listed above, but I have not received the
merchandise or service. I expected to receive
from the merchant on / / . I contacted the merchant on _/ / , and
their response was
. This matter has not been resolved.
The merchant promised me a refund credit for the listed charge, but it has not yet appeared on my
card. A copy of the refund documentation is enclosed. (If store credit, send copy of sales slip and
credit slip. Specify the reason for not using store credit:
.)
I have been charged the wrong amount. Enclosed is a copy of my receipt showing the amount for
which I signed. My receipt shows $ . , however, I was billed $ . .
My card number was used to secure this purchase; however, the final payment was made by
check, cash, or another credit card. Enclosed is my receipt, canceled check (front and back),
copy of credit card statement, or applicable documentation demonstrating that payment was made
by other means.
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Transaction Dispute Form / Written Statement of Unauthorized Debit
Section C – Dispute Reason (continued)
If none of the above reasons apply: Please print this form and provide a complete description of
the problem by detailing your attempted resolution with the merchant and outstanding issues.
Also enclose any documentation that may support your claim.
Section D – Claim Number
If you have already submitted this dispute over the phone, please provide the claim number you were given.
My claim number is: SF- .
(If you have not submitted this dispute via phone, you may leave this blank.)
Section E – Cardholder Signature
I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I
attest that the debit(s) below was (were) not originated with fraudulent intent by me or any person acting in
concert with me.
I have read this statement in its entirety and attest that the information provided on this statement is true and
correct.
Cardholder’s Signature: Today’s Date: / /
(mm / dd / yyyy)
2nd Cardholder’s Signature: Today’s Date: / /
(mm / dd / yyyy)
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