CARDHOLDER DISPUTE FORM
This form has been provided for your convenience. If you believe that a transaction on your account is in error, you can
use this form to dispute the transaction in question. Please be advised that Mastercard® requires that attempts be
made to resolve your dispute with the merchant before notifying us.
So that we may serve you better, please let us know immediately, that you are planning to dispute a transaction by
identifying the transaction online. This can be done using the cardholder website on the back of your card.
Your card must be registered in order to file a dispute. Accounts can be registered using the cardholder website
printed on the back of your card. In case you are experiencing an issue registering your card online please call
the customer service number listed on the back of your card or the number on the website for your virtual
account.
In order to process your dispute, regulations require that you notify us in writing within 60 days from the date
of the disputed transaction(s). Any response received after this time frame will not be processed.
Please complete and mail, email or fax a copy of this form along with any supporting documentation to:
Mailing Address: Email: Fax Number:
ATTN: Cardholder Dispute Services dispute.support@bhnetwork.com (623) 399-1301
10615 Professional Circle Ste. 102
Reno, NV 89521
PLEASE DO NOT ALTER THE WORDING ON THIS FORM
PERSONAL INFORMATION (Please fill this section out completely. Failure to do so will result in a
delay of your claim resolution.)
KYSHA GONZALEZ
Your Name: __________________________ 6039530400058438295
Proxy Number: ________________________________________
(19-digit number above barcode on back of card)
If no 19-digit Proxy number is available, please provide the last 4 digits of the 16-digit card number: _______________ 4596
DS0592494
Case#: ______________________________________
Case# only required if you have already been provided one
3613668044
Telephone Number: ____________________________ Best time to call: _______________________________
110 EAST KENNEDY ST
Address Line 1: ________________________________________________________________
BENAVIDES TX
Address Line 2: ______________ City: ______________ State: _____ Zip Code: ____________ 78341
Bigo.wife@icloud.com
Email Address: ________________________________________________________
Transaction Information (please refer to your statement for assistance)
2023-10-07
Posting Date: ___________________
$3.24
Transaction Amount $: _____________________________ $3.24
Disputed Amount $: ______________
Prime Video Channels
Merchant Name: ________________________
✘
Disputing more than one item? Yes ___ No ____
2
If yes, enter the number of items disputed: ___ (e.g. 3)
Select the dispute reason below for the transaction listed above and complete additional disputed transactions on the last page.
Type of Dispute (Select one)
Charged twice for the same transaction – I certify that the charge in question was a single transaction but
was charged twice to my account. I did not authorize the second transaction.
• Sale # 1 (Valid Transaction) $________________
• Sale # 2 (Invalid Transaction) $________________
Cancellation (hotel, good, services …) – Please enclose copy of letter, email, or fax informing the merchant
of cancellation.
• Date of cancellation ________________ Cancellation # _____________________________
• Reason for cancellation ______________________________________________________
Merchandise was returned - Please attach signed copy of proof of return.
• Reason for returning ______________________________________________________
• If you are unable to return the merchandise, please explain
_________________________________________________________________________
Merchandise not received - Please notify the merchant of non-receipt.
• I have not received merchandise that was to be shipped or picked up on (mm/dd/yy) ____/____/____
• I have asked the merchant to credit my account No ____ Yes ____
• If Yes, when? ____/____/____
Merchandise shipped was either damaged or defective - You must explain in detail how the merchandise
was damaged or defective, provide proof and attempt to return the merchandise prior to exercising this right.
• I have asked the merchant to credit my account No____ Yes____
• If Yes, when? ____/____/____
Overcharged for a transaction - Please include a copy of the signed sales receipt.
• The amount was increased from $ ________ to $ ________
Credit posted as a sale - Please attach a copy of the credit slip and the original sales slip.
No show hotel charge - Please describe in writing what occurred. Provide information or documentation
showing the reservation was canceled.
Transaction did not complete - Please describe in writing what occurred.
• I have asked the merchant to credit my account No ____ Yes ____
• If Yes, when? ____/____/____
• If no, explain why? __________________________________________________________________
Credit not posted to account - Please enclose a copy of the credit slip or notice of credit from the merchant and
a detailed explanation of your dispute. The merchant has 30 days to credit your account.
Transaction paid by other means - You must provide proof of paid by other means such as a copy of the
canceled check (front and back), a cash receipt, or a statement from another credit/debit card account.
Service Dispute - Please describe the nature of your dispute and your attempts at resolution in writing with this
form. Include copies of second opinions from a certified professional, repair bills, contracts or other supporting
documentation.
✘ Unauthorized charge - I certify that I did not authorize or participate in this transaction with the above mentioned
merchant, nor did I authorize anyone else to use my card. To use this option, you must report the unauthorized
activity to us immediately.
Additional Disputed Transactions
Use the table below to list your additional disputed transactions. Completely fill out the table and choose the appropriate
Dispute Type from the section above. Supply the required supporting documentation listed base on the Dispute Type
selected.
Please refer to your statement for assistance.
Posting Date Transaction Dispute Merchant Name Type of Dispute (select type from list
Amount Amount above)
2023-10-07 $9.73 $9.73 Prime Video Channels Unauthorized charge
SIGNATURE REQUIRED _____________________________________ DATE_________________________
Please keep the original for your records
Mastercard is a registered trademark, and the circles design is a trademark of Mastercard International Incorporated.
