EXPRESS CARD DISPUTE FORM
| CARDHOLDER NAME: | ________________________________________________________________ |
| CARDHOLDER PHONE NUMBER: | ________________________________________________________________ |
| CARDHOLDER FAX NUMBER: | ________________________________________________________________ |
| CARDHOLDER ACCOUNT NUMBER: | ________________________________________________________________ |
| VENDOR NAME: | ________________________________________________________________ |
| TRANSACTION AMOUNT: | ________________________________________________________________ |
| TRANSACTION DATE: | ________________________________________________________________ |
| TRANSACTION REFERENCE NO: | ________________________________________________________________ |
| DEFAULT INDEX | ________________________________________________________________ |
|
To assist with the investigation, please indicate the reason for your dispute. If you have any questions, please call our Dispute Representative at (858)534-6535. |
|
| ____ | I did not make nor authorize the
above transaction. (Please indicate the whereabouts of your
Purchasing Card (Express Card).
_____________________________________________________________ |
| ____ | There is a difference in the amount
I authorized and the amount I was billed. (A copy of your charge
must be enclosed). |
| ____ | I only transacted one charge, and I was
previously billed for this sales draft.Date of previous charge: _____________________________________________________________ |
| ____ | The above transaction is mine, but
I am disputing the transaction. (Please state your reasons why in
detail). _____________________________________________________________ _____________________________________________________________ |
| ____ | Please send me a copy of the sales
draft. (Your account will be charged $5.00 for each copy supplied). |
| ____ | I have received a credit voucher
for the above transaction, but it has not yet appeared on my
account. (A copy of the credit voucher must be enclosed). |
| ____ | My account has been charged for the
above transaction, but I have not received the merchandise. The date
of expected delivery was: ______ The details of my attempt to
resolve the dispute with the merchant and the merchant’s
response is listed below: _____________________________________________________________ _____________________________________________________________ |
| ____ | My account has been charged for the above
transaction, but the merchandise has since been returned. The details
of my attempt to resolve the dispute with the merchant and their response
follows: _____________________________________________________________ _____________________________________________________________ |
| Cardholder Signature: ____________________________________ Date: __________________ |
|
| Send completed form to: Mail Code 0955 Disputes Representative (7/04) |
Or fax to: (858) 534-7194 |
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Official
Web Page of the University of California, San Diego
Last Updated 7/1/2004 |