Written Dispute Form
Name: KATHRYN RICHARDSON
Card Number: 9367
Dispute Claim #: 992132
Please confirm the transaction(s) in dispute:
☐ Yes ☐ No 06/30/2024 AMRO INVESTMENTS $5.00
☐ Yes ☐ No 07/23/2024 CITY TELE COIN COMPANY, 318-629-1595 $19.56
☐ Yes ☐ No 07/29/2024 NCIC INMATE PHONE SERVICE, $20.00
☐ Yes ☐ No 07/30/2024 NCIC INMATE PHONE SERVICE, $13.00
☐ Yes ☐ No 08/14/2024 SMART AND FINAL 444 $3.63
☐ Yes ☐ No 09/01/2024 PETCO 5125 $13.13
☐ Yes ☐ No 09/02/2024 TARGET 00024794 $2.59
☐ Yes ☐ No 09/08/2024 TARGET 00008839 $20.62
☐ Yes ☐ No 09/08/2024 PASADENA CENTER PARKING $15.00
Please complete the section below that best pertains to the reason for your dispute:
☐ Unauthorized Transaction
The charge(s) listed above were not made by me or anyone authorized to use my card/account.
Goods and services were not received by me, or anyone authorized to use my card/account.
At the time of charge(s), my card was: ☐ In my possession ☐ Lost/Stolen ☐ Never Received
If lost/stolen, what day/date did this happen? ________________________ Was anything else
lost/stolen with the card? ☐ Yes ☐ No If yes, what? ______________________________________
Do you know who made these transactions: ☐ Yes ☐ No If yes, who? _______________________
Have you given anyone permission to use your card/account? ☐ Yes ☐ No If yes, who? ________
Where do you normally store your card: ________ Where do you normally store your pin: _________
When was the last time you used your card? Date/Amt/Merchant: ____________________________
☐ Cash Not Received
I requested $_______________ but I received $________________.
☐ Incorrect Transaction Amount
The dollar amount of the transaction was for $________ but my account was charged $__________. *
Please attach a copy of the sales receipt showing the correct amount to this form.
☐ Duplicate Transaction
The above transaction is a duplicate of an authorized transaction on date: _____ Amount: $_______
☐ Cancelled Transaction / Service / Merchandise
I cancelled this transaction with the merchant on date: ____________ but I was charged anyway. Was
any merchandise received as a result of this transaction: ☐ Yes ☐ No If yes, what was received?
_______________________________ Was the merchandise returned? ☐ Yes ☐ No If yes, please
provide tracking information: ________________________________________________.
☐ Paid By Other Means
I paid for this exact transaction using a different means on date: _________ using ______________. *
Please attach a copy of the statement showing the alternative payment to this form.
☐ Merchandise or Service Was Not Received
I ordered _________________________________ from this merchant. I expected to receive
goods/services on date: _____________ but I have not received anything. I contacted the merchant
on date: ______________ and was advised
_______________________________________________________________.
☐ Merchandise or Service Was Not As Described
I ordered _______________________ from this merchant. Instead, I received
_______________________. I contacted the merchant on date: ___________ and was advised
_____________________. Was the merchandise returned? ☐ Yes ☐ No If no, why not?
_____________________________________________
☐ Other
Describe the circumstances and provide all information that would help our investigation. Please use
additional pages if needed:
____________________________________________________________________________________
____________________________________________________________________________________
Please be sure all information is accurate before signing this form. By signing below, you agree you
have reviewed this document and are ensuring all information is accurate. Please return the
completed form and any supporting documentation by emailing it to
disputeinvestigations@payactiv.com.
Signature: __________________________________ Date: _____________Phone: _________________
