8/10/2019 Dispute Form - Prepaid NonReloadable
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1 | P a g eOnePayThe Leading UK Payroll Card
Registered in England No: 05934955, Registered Address Wells
Road Business Centre, Wells Road, Ilkley, LS29 9JB
Customer Transaction Dispute Form
PLEASE COMPLETE ALL SECTIONS AND RETURN SIGNED FORM WITH ANY
DOCUMENTATION TO ONEPAY
Use a separate form or additional pages to document each
dispute.Fax to: 01133 200 254 Email:[email protected] If you
have any questions, please call 01133 201 900.
Full Name: Date of Birth:
Address:
Email:
Mobile No: Home Phone:
Card No:4 7 2 6
Transaction Amount: Disputed Amount: Transaction Date: / /
Merchant Name(s):
(Please tick the ONE that is most appropriate and ensure that
you attach any supporting documentation you have )
(1) I do not recognise the transaction, please give details.
(2) I used the ATM on that day and received partial funds or no
funds at all.ATM receipt attached: [ ] Yes [ ] No
(3) I have not authorised or participated in the transaction(s)
or Internet transaction(s) listed above.
Please note that if you have ticked this box your card may be
stopped and you may be asked to return your card.
(4) I only authorised one transaction for ________ on ___ / ___
/ ___. It appears to be duplicated on ___ / ___ / ___.
(5) I only authorised one transaction for ________ on ___ / ___
/ ___. It appears to be processed for the incorrect amount
of______________. Please attach a copy of sales receipt and any
other applicable documentation.
(6) A credit for ________ was not processed on ___ / ___ / ___.
Merchandise was returned / Services were cancelled on ___ /___ /
___. I last contacted the merchant about this matter on ___ / ___ /
___.
Please attach a copy of the credit transaction receipt.
(7) I have not received the goods or services I have paid for.
They were expected on ___ / ___ / ___. I have contacted the
merchant totry and resolve this matter on ___ / ___ / ___.Please
attach a copy of document(s) showing the expected service or
delivery date.
(8)) The goods or services I have paid for were damaged /
defective or not as described. I returned the goods / cancelled the
serviceson___ / ___ / ___. I have contacted the merchant to try and
resolve this matter on___ / ___ / ___.Please describe and provide
evidence (e.g. invoice) of the damaged / defective / not as
described goods or services. Please
provide proof that the goods were returned / services cancelled
or an attempt was made.
(9) I paid for the goods or services by other means and my card
/ account was debited. E.g. cash, another credit card,
cheque.Please attach copy of document(s) supporting this claim.
IMPORTANT: If this form is not received within 5 days, no
further action will be taken by OnePay. Once the completed form has
beenreceived, your dispute will be reviewed and if necessary the
result posted within 30 days to your address.Please note some
merchants may take 30 days to respond.
Customers Signature: Date: / /
mailto:[email protected]:[email protected]:[email protected]:[email protected]
