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]
[// GUIDANCE: New York cardholders may have additional state law remedies; this template is for issuer chargeback submission only.]
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