Transaction Dispute Form
Please complete all sections of the form (as applicable).
If you have not done so already, you may also call us (see the back of your card OR the ‘Contact Us’ section on our website for our Customer Support
phone number) during business hours to file your dispute directly with us. (This form may still be requested by your customer support representative.)
Please provide all relevant information about your dispute, including all information you may have previously provided to a customer support
representative, if applicable.
Card Details
Card Number Case Number
(Last 4 numbers on the front of your card) (A customer support representative may have verbally provided this to you when
you filed your dispute. If you did not call, please write "N/A" in this section.)
Disputed Transactions
Please list all transactions you wish to dispute. If you need to list additional transactions, please include an additional page.
Date Merchant name Amount
$
$
$
$
Reason for Dispute
Please check the box(es) most appropriate and attach any corresponding documentation (if applicable).
I authorized and participated in the transaction(s) provided but have the following issue:
Duplicate transaction Credit not received
Expected refund amount $
Processed for the incorrect amount
Expected refund date
Amount expected to pay $
Amount charged $
I have not received the goods or services I paid for.
Paid by other means They were expected on:
By what other means did you pay?
(e.g. in cash, 1/2 on another card, etc.) Date
I attempted to withdraw cash from an ATM:
I have contacted the Merchant to try to resolve this
matter. My last contact was on: Amount requested $
Date Amount received $
Other (Please specify)
NOTE: Please include copies of any of the following: proof of credit/refund receipt, email, letter, sales receipt ATM receipt, proof that the
goods were returned, services were cancelled, or an attempt was made in addition to any details of the merchant’s response (as applicable).
I have not authorized nor participated in the transaction(s) listed above and:
Please note that if the above transactions are identified as fraudulent, and your card/account has not yet been secured, it may require the
cancellation of your card and issuance of a new one.
I have never done business with this merchant. I have done business with this merchant in the past, but I
did not authorize the above transaction(s).
For transactions reported as not authorized, please confirm the following:
My card is in my possession
Where do you keep a record of your PIN?
(memorized, written down, all details are helpful.)
Has your PIN been shared with anyone else?
(including family members) Yes No
Has your account login information been shared
Yes No
with anyone else?
If Yes, please provide details
My card was lost or stolen
Date and time loss/theft occurred: Date Time
Was your PIN lost/stolen as well?
If Yes, please provide any details below Yes No
Describe how and when you became aware of loss or theft
(please provide as many details as possible, e.g., scenario which loss or theft occurred etc., details will assist us in the investigation process).
Police Report Details (if applicable)
What date and time did you report to the police? Date Time
Police report number Police officer’s name
Contact number Station/Location
Additional Information
Please provide any additional information that may be helpful in assisting with your dispute.
Signature
I certify that my statements in this transaction dispute form are true, complete, and correct to the best of my knowledge and
belief. I understand that all statements made regarding this dispute may be investigated.
Signature Printed Name Date
Please return this completed form and any supporting documents to:
Green Dot Corporation
ATTN: Disputes
P.O. Box 9
West Chester, OH 45071
