CARD TRANSACTION DISPUTE
Application Form
IMPORTANT INFORMATION:
• Debit Cards: You must inform us immediately and no later than 30 days after the date of the account statement about any suspected
unauthorized transaction.
• Credit Cards: You must inform us immediately and no later than 20 days after the date of the statement generated date about any
suspected unauthorized transaction.
• For clarification or further information, please contact us on Tel +960 333 0200
S EC TI O N 1 - YO U R D E TAILS
Cardholder Name
(as in ID Card/
Passport)
Last four digits of
ID Card No.
card number
Type of Card Mailing Address
House /
VISA Debit Mastercard Debit Street Name
Building Name
Flat No. /
VISA Credit Mastercard Credit Atoll, Island
Floor No.
Amex Debit Mastercard Business Post Code Country
Amex Credit Mobile No. Email
NOTE: All transactions specified must be disputed for the same reason. If different reasons apply, please submit separate forms for the
separate transactions. ( If more than 3 transactions, please attach a statement copy with the disputed transactions clearly marked )
S EC TI O N 2 - D I S PUTED TR A N SAC TI O N S
Date Description/Merchant Name Transaction Currency & Amount Billed Amount (USD/MVR)
Signature: Page 1 of 3
S EC TI O N 3 - D I S PUTE R E ASO N S
Transaction not authorized by cardholder/possible fraud: The transaction was not authorized by you or any supplementary
cardholder. Note: Some business establishments may use their corporate name for billing, which can be different from their public
name or the name of the specific Merchant outlet.
*If you have engaged in prior transactions at this Merchant, please provide details of the latest valid transaction.
• Card replacement: Issue me a replacement card
Note: Please be informed that the disputed card will be deactivated for security reasons as the dispute has been submitted as
transaction not recognized/possible fraud and note that the card cannot be reactivated any further.
Paid by other means: You used your credit card as a guarantee and subsequently used another form of payment, but your credit
card was charged. Note: Please provide supporting documentation to show your other means of payment.
Incorrect transaction amount: transaction amount charged to your account is different from the amount on your invoice or sales
receipt. Note: For transactions in currencies other than billing currency, transaction amount will be shown in your statement under
details.
Duplicate charges: Your account was charged more than once for the same transaction.
Cancelled transaction: You cancelled a reservation, transaction, or recurring transaction and your account has been charged
after the cancellation date. Note: Please check for any valid charges applicable as per cancellation policy of the Merchant
advised/ accepted prior to the transaction, and submit your dispute only if you feel the charge is not valid. Please provide copy of
cancellation policy and any correspondence regarding the cancellation.
Merchandise/services not received: You ordered merchandise or service that was never delivered, but your account was charged.
Not as described or defective merchandise: You received merchandise that was damaged / defective, or the merchandise /
service did not match the description on the transaction receipt or other documentation presented at the time of purchase. Note:
Prior to disputing the charge, please attempt to return the goods / cancel the service, and resolve the matter directly with the
Merchant. Please provide supporting documentation to show description of what was purchased and what was received. Please
also provide details of your attempts to resolve the matter with the Merchant.
Refund not processed for merchandise / services returned: You have not received a credit due to you from the Merchant for
returned merchandise and/or service. Note: Please provide credit slip and/or proof of return, and any other documentation to
support your claim.
Non-receipt of cash at ATM: You did not receive the full amount of cash on ATM transaction. Note: Please attach ATM receipt copy.
Other: For all other dispute reasons. Please provide details of your dispute below. If space is insufficient, summarise below and
attach details.
Additional information: (Please provide any additional information to support your claim, and list all attached documents)
Signature: Page 2 of 3
C A R D H O LD ER ' S D EC L A R ATI O N
I confirm that neither I nor any supplementary cardholder in any way authorised any transaction being disputed as ‘not authorised’ in this
form; or are aware that any amount disputed in this form is in fact a valid charge.
.................................................................................................................
Primary Cardholder's Signature Date
Total Pages including this
form:
FO R BAN K U S E O N LY
Staff Name Staff ID Signature
Date D D M M Y Y Y Y Time H H M M
Signature: Page 3 of 3
VERSION: 1.1
