CHARGEBACK DISPUTE SUBMISSION

To: [Card Issuer Dispute Dept.]
From: [Cardholder Name/Address]
Date: [DATE]
Account Last 4: [####]
Transaction: [$], [DATE], [Merchant], [Location/Online], Auth/Receipt No. [####]

1. REASON FOR DISPUTE (SELECT)

• Unauthorized/fraud (card not present/stolen).
• Goods/services not received.
• Goods/services not as described/defective.
• Duplicate/incorrect amount/credits not processed.
• Canceled recurring/returned merchandise.

2. FACTS AND STEPS TAKEN

• Description of issue and any contact with merchant (dates, responses).
• Cancellation/return dates, RMA numbers if any.
• Outcome of merchant contact [no response/refused/partial credit].

3. REQUEST

• Issue chargeback for [$] and credit my account; block future recurring charges (if applicable).

4. ATTACHMENTS

• Receipts/invoices/order confirmations.
• Communications with merchant (emails/chats).
• Return proof (tracking, RMA).
• Photos/videos showing defect/variance.
• Police report/affidavit for fraud (if applicable).

Signed:
[Cardholder Name]