Customer Dispute Form
Important: Please be aware your employer cannot assist with dispute requests. You must contact Money Network Customer Service
directly, using the number on the back of your Card, to initiate your dispute before submitting this document.
01-06-2006
Date*: __________________
0119
________________________
Card Number* (last 4-digits)
Sincere Turner
_________________________________________________________________________________________________________
Cardholder Name* (First and Last Name)
7003 Lachlan Circle Apt L
_______________________________________________ Baltimore
___________________ Maryland
____________________
21239
____________
Address* City* State* Zip*
Claim #*: _____________________________
Lost/Stolen:
Is the Card in your possession? Yes No If no, was the Card: Lost? Stolen?
Date Lost or Stolen: _________________ Cardholder Discovery Date: ________________
Date loss or theft was reported to Money Network: _________________
Have you ever authorized anyone else to use your Card? Yes No If yes, who? ___________________________
Please list the transactions below that you are disputing and complete page 2. If you need additional space, you can include detail
on page 3 with all transactions being disputed.
Post Date Amount Merchant Description Transaction Date
10/21/2024 102.50 FRIENDLY G 233 S FULTON AVE 10/21/2024
10/26/2024 102.75POPPLETON 805 W LEXINGTON 10/26/2024
11/09/2024 180.00WALGREENS #1-W 6838 LOCH RAVEN 11/09/2024
11/12/2024 102.75 POPPLETON 805 W LEXINGTON 11/12/2024
11/12/2024 182.75 POPPLETON 805 W LEXINGTON 11/12/2024
11/12/2024 202.75 POPPLETON 805 W LEXINGTON 11/12/2024
11/28/2024 200.00 7ELEVEN-FCTI 38 S PACA ST 11/28/2024
12/13/2024 170.99 CHINA GARD 236 N. EUTAW ST. 12/13/2024
Please return all pages of this document and any additional supporting documentation via one of the following methods:
Print and Mail Print and Fax Email
DISPUTES Fax: 1-402-916-8249 PrepaidCardDispute@fiserv.com
P.O. BOX 2059 (Email documents in TIF or PDF only)*
Omaha, NE 68103-2059
*Required
© 2024 Money Network Financial, LLC. All Rights Reserved. All trademarks, service marks and trade names referenced in this material are the property of
their respective owners. Cards issued by Pathward®, N.A., Member FDIC.
Please complete the following information to the best of your ability to assist us in working your claim. You may also consider
contacting the merchant directly to assist in resolving your dispute.
Check reason for dispute. If needed, include any relevant documents such as receipts or shipping confirmations.
Duplicate Processing Paid By Other Means
Original transaction authorized ____________________ Original form of payment: Cash Card
for $ ____________________ Please provide copy of receipt or proof of payment.
Merchandise Not Received Services Not Rendered
Product ordered _____________________________________ Service expected __________________________________
Shipped date __________________ Supposed received date _________________
Attempt to resolve? Yes No Attempt to resolve? Yes No
Delivered to wrong address? Yes No Merchant contact date __________________
Merchant contact date __________________
Merchandise Returned Credit Not Received
Shipped/Returned date ___________________ Merchant contact date _________________
Attempt to resolve? Yes No Partial credit: Yes No If yes, $________________
Include return/shipping receipt or relevant merchant correspondence. Include return/shipping receipt or relevant merchant correspondence.
Cancelled Transaction Quality Problem
Cancelled transaction date ___________________ Describe in detail on page 3
Cancellation number: ________________________________ Attempt to resolve? Yes No
Merchant contact date _________________
Unauthorized Transaction ATM Non-Dispense
Neither I, nor anyone, authorized by me engaged in the Amount received from the ATM $ ___________________
transaction with the above listed merchant.
Other
Describe in detail below or attach a detailed explanation. Include all documentation supporting your dispute.
This statement of unauthorized debit is true and correct, I am authorized as the account holder, an authorized signee, or person
with corporate authority to act on this account.
____________________________ _________________
Cardholder Signature Date
____________________________
Telephone Number(s)
© 2024 Money Network Financial, LLC. All Rights Reserved. All trademarks, service marks and trade names referenced in this material are the property of
their respective owners. Cards issued by Pathward®, N.A., Member FDIC.
Additional Details
© 2024 Money Network Financial, LLC. All Rights Reserved. All trademarks, service marks and trade names referenced in this material are the property of
their respective owners. Cards issued by Pathward®, N.A., Member FDIC.
