"Disputed Transaction Form" - Colorado

Disputed Transaction Form is a legal document that was released by the Colorado Department of Military and Veterans Affairs - a government authority operating within Colorado.

Form Details:

  • The latest edition currently provided by the Colorado Department of Military and Veterans Affairs;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Colorado Department of Military and Veterans Affairs.

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Download "Disputed Transaction Form" - Colorado

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DISPUTED TRANSACTION FORM
Cardholder Name & Address
Account Number :____________________________
__________________________________
Cardholder Phone Number: ___________________
__________________________________
Cardholder Fax Number: _____________________
__________________________________
Merchant Name: _____________________________
__________________________________
Amount: ___________________________________
Transaction Ref #: _____________________
Transaction Date: ____________________________
To assist our investigation, please indicate below the reason for your dispute.
I did not make nor authorize the above transaction. (Please indicate the whereabouts of your Procurement 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.
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 this merchandise. The date of
expected delivery was: ____________. The details of my attempt to resolve the dispute with the merchant and
the merchant’s response are indicated below.
____
Other (Please explain):___________________________________________________________________
Cardholder Signature: _____________________________________________
Date: ________________
DISPUTED TRANSACTION FORM
Cardholder Name & Address
Account Number :____________________________
__________________________________
Cardholder Phone Number: ___________________
__________________________________
Cardholder Fax Number: _____________________
__________________________________
Merchant Name: _____________________________
__________________________________
Amount: ___________________________________
Transaction Ref #: _____________________
Transaction Date: ____________________________
To assist our investigation, please indicate below the reason for your dispute.
I did not make nor authorize the above transaction. (Please indicate the whereabouts of your Procurement 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.
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 this merchandise. The date of
expected delivery was: ____________. The details of my attempt to resolve the dispute with the merchant and
the merchant’s response are indicated below.
____
Other (Please explain):___________________________________________________________________
Cardholder Signature: _____________________________________________
Date: ________________