Application Form For Disputed Transaction (to be submitted by Cardholder)

Company Name(s): 

LETTER TO BE SUBMITTED BY CARDHOLDER FOR DISPUTED TRANSACTION
From, Date: _________________ Name: _________________________ Address: _________________________ _________________________ _________________________ _________________________ Phone No.: _________________________ e-mail id: _________________________ To, The Asst General Manager SyndicateBank: Card Centre 69, 9th Main Road, 3rd Block Jayanagar BANGALORE - 560 011. Dear Sir, Ref: My SyndicateBank Global Credit Card No. _________________________________ This is to inform that the following transaction appearing in the Billing Statement as on ____________ received by me has not been carried out by me/ was unsuccessful (strike out whichever not applicable)-
Transaction attempted Through
Name of the Bank / Establishment
Location of ATM/ Merchant Establishment
ATM
POS at Merchant Establishment
Transaction Details are as follows:
Details
Date of Transaction
Amount attempted through Transaction
Amount received (Partial dispensing of Cash)
Amount Disputed
Reason/s for Dispute/s is/are as follows:
Reasons for Dispute
Amount reflected in the Billing Statement but Cash not dispensed by the ATM
Amount reflected in the Billing Statement but Partial Cash dispensed by the ATM
Amount reflected in the Billing Statement but transaction not successful at POS (Merchant Establishment)
Single transaction processed more than once at POS/ATM
Amount reflected in the Billing Statement but transaction not recognised / authorised by me. It may be deemed as a fraudulent transaction.
I request that the transaction may please be verified and suitable action may be initiated to reverse the amount with relevant charges in my Credit Card account. In case the disputed transaction is decided in favour of acquirer as per VISA Dispute Resolution Rules, I hereby authorise you to debit my Credit Card account with principal amount and relevant charges, including charges claimed by the acquirer bank, from the value date of the transaction. I undertake to pay the entire amount in such event. Yours faithfully, (Signature of the Cardholder)