CARDHOLDER DISPUTE APPLICATION FORM
(PLEASE FILL THE FORM IN CAPITAL LETTERS) ALL FIELDS ARE MANDATORY
Date: D D M M Y Y Y Y
Dear Sir/Madam,
(Tick ( ) as Appropriate) Primary card Addon card
Name of the Cardholder:
Credit Card Number (First 6 digits & Last 4 digits):
Registered Mobile Number:
Additional Mandatory Information (Customer ID (For account holders) / Registered Email ID):
I am raising a dispute for the below listed transaction(s) for the reason(s) selected in the Dispute Reasons section.
Transaction Date Merchant Establishment Transaction Amount Dispute Amount
Dispute Reasons: Please tick ONLY the most appropriate option
*Not authorized - I have neither authorized nor participated in the transaction(s)
*Card was in my possession, not in my possession - Lost / stolen on _________ at __________ Card was
never received
*I have authorized only for free transactions, but received recurring billing for paid services by the merchant
(Digital/ E-commerce/ Online transactions)
Difference in Amount charged – I was debited for _____________________ whereas the actual transaction amount
was _____________________
Duplicate/ Multiple billing – I have done only _____ transaction(s) but I was billed for _____ transaction(s)
(mention number of times)
Paid by other means – Please enclose proof of payment made by cash/ cheque/ other bank card
Goods/ services not received – I have ordered for _____________________ on ________________ and the expected
date of delivery was ______________ but I have not received the goods/services as on ________________ and I
have contacted the merchant on ____________________.
Mail correspondence with the merchant Product description (proofs enclosed)
Failed Transaction – I have attempted the above transaction, but it was unsuccessful. However my account has
has been charged. I have contacted the merchant on _____________.
Mail correspondence with the merchant Product description (proofs enclosed)
Defective Product/ Product not as described – I am disputing the goods / services received as defective / not as
described.
Mail correspondence with the merchant Product description of what goods / services were expected
and what was received
Product / Merchant returned -
I have returned the product to the merchant on _____________ by couriers / post vide awb# _______________
(or) handed-over at merchant place directly and requested merchant for refund (proofs enclosed) . The reason
for return was________________________
I have contacted the merchant on _______________ and attempted to return the product
Cancelled transactions –
I have cancelled the membership/ subscription/ booking on _____________ against the above charge.
Mail correspondence with the merchant Cancellation code provided by merchant _______ (proofs enclosed)
Credit not received –
Merchant has given a refund confirmation void/ credit slip for an amount of INR _________ on _____________
However, Credit is still not reflecting in my statement I have received a debit instead of a credit
Mail correspondence with the merchant Confirmation or void/ credit slip attached (proofs enclosed)
ATM: Cash not dispensed – Cash was not dispensed by the ATM but my account was debited for _____________
on ______________
ATM: Partial cash dispensed – I received cash for ____________ but my account was debited for ______________
on ______________
Hotel Reservation / Flight Booking:
I have cancelled the booking / reservation on _____________ under the cancellation code/ reference no
_______________
(proof enclosed)
I have not made any booking / reservation
Others (please explain in detail) –
*Card needs to be mandatorily hot-listed through YES BANK Customer Care. In case of unauthorized transaction(s), please file
police complaint and submit the relevant documents with Bank.
Declaration: I declare that above given information is true and correct to my knowledge. In case, if any of the information mentioned
above is found to be incorrect and misleading, YES BANK has the right to reject the dispute. I understand that I can be held liable
for all charges incurred if dispute raised by me is found to be invalid. I agree to pay the charges levied by YES BANK for the same
including any cost and expenses incurred for investigation of my disputed transaction(s). YES BANK may contact me whenever it
requires any further information and I agree to co-operate with YES BANK in every manner possible.
Card-holder Signature: ____________________________________________
Card-holder Name: ______________________________________________
Please download and print this form, fill in the required details, include all relevant documents such as
correspondence with the merchant, cash receipt, postal receipts etc. (as specified against the nature of dispute in the
form) and send it electronically to cc.cdf@yesbank.in, within 7 days from the date of raising your dispute complaint
with us, for enabling us to review the dispute and act further.
(Or)
You can courier the physical form along with the relevant documents Credit Card Division, YES BANK Ltd., YES
BANK Towers, Plot no 14, 3rd Main road, Ambattur Industrial Estate, Ambattur, Chennai – 600058.
