Credit Card Dispute Form - California

114006_FM_Credit_Debit_Card_Dispute_Rev._0712
Credit/Debit Card Transaction Dispute Form
If a transaction appears on your statement that you believe is an error, and you have been unable to resolve the situation with the merchant,
please complete the form below. We must receive this form within 60 days of the closing date as printed on your statement. Please fax this form
and any supporting documentation to 925.847.3653. Or, send by mail to Patelco at PO Box 2227, Attn: Card Services, Merced, CA 95344-0227.
You may also submit this form at any branch.
() ()
Member Name Account Number Home Phone Work Phone
Merchant Name Transaction Amount Transaction Date
Member Signature (Required) Date Credit Card Number
I contacted ________________________________ (merchant name) on _______________ in an attempt to resolve this dispute.
Please supply a sales receipt copy. (Member signature not required.)
Although I did participate in a transaction with the merchant, I was billed for _________ transaction(s) totalling $ ___________ that I did not
participate in, nor did I authorize anyone else to use my card. I do have all my cards in my possession. Enclosed is a copy of my sales slip for
the valid charge.
I have not received the merchandise that was to have been shipped to me. Expected date of delivery was _________________ .
I contacted the merchant on ______________ and the merchants response was: ________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
(In order for us to assist you effectively, you must contact the merchant and inform us of their response.)
I have returned merchandise on _____________ because ___________________________________________________________________ .
(Please provide a copy of the return receipt or proof of return.)
I was issued a credit slip for $ ___________ on _____________ , which did not appear on my statement. A copy of my credit slip is enclosed.
I have been billed an incorrect amount. My credit card receipt shows $ ___________________ . However, I was billed $ __________________ .
(Please include a copy of your sales receipt.)
I have been billed more than once for the same transaction. I authorized only one charge with the merchant for $ ______________________ .
(Please include a copy of your sales receipt.)
I notified the merchant on ____________ to cancel the pre-authorized order (reservation). My cancellation number is _________________ .
I was / was not (circle one) informed of the cancellation policy when I made the reservation. The reason I cancelled was:
_________________
______________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________ .
(If you do not have a cancellation number, please provide a copy of your phone bill showing the date and time of the cancellation call.)
I cancelled the subscription/membership/policy (circle one), which was charged to my account by the above-referenced merchant on
____________________. I cancelled the charge prior to the transaction date.
The transaction was paid by other means. (Please provide a copy of cash receipt, the front and back of your cancelled check, or a copy of your
statement if another credit card was used.)
Other (describe on reverse). Please include what attempts have been made to contact the merchant and resolve the situation.
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