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Name: __________________________ Claim Number If Known: ____________

Address: ________________________ Account Number: _________________
City: ___________________ State: ______ Zip: _________
Dispute Report Form:
I am disputing the following charge(s) on my account:

Merchant___________ Posting Date Amount_____

1.) ___________________ __________________ ______________
2.) ___________________ __________________ ______________
3.) ___________________ __________________ ______________
We understand that you are disputing a charge made to the account noted above. If you have not
already done so, please first contact the merchant directly to resolve this matter. If you are not
successful, please provide the information requested below. Then sign this form and return it as soon as
possible, to the address below.

Important: Please answer each question so that we may research your dispute properly.

Did you authorize this charge: ___________ Yes ___________ No

Reason for dispute (please address each disputed transaction in your description):

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Please describe your dispute in detail, and the steps taken to resolve the dispute with the merchant. (For
more space, use the blank space at the bottom of this form or attach an additional sheet)
_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Continued

JPMorgan Chase Bank, N.A. OH1-0553 P.O. Box 182879 Columbus, Ohio 43218-2879
Facsimile 877-875-1856
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_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

I have contacted the merchant in an effort to resolve this matter and received the following response:

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

I contacted the merchant on (date) ________________________ and spoke to (name):_______________________

Was merchandise returned? __________Yes ___________No

If “Yes”, please enclose a copy of your return receipt, return tracking information for the package and
anything else to support the return.

I am disputing the charge for the reasons explained on the previous page. I have attempted to resolve
this with the merchant; however, no adjustment has posted to my account. I am enclosing copies of all
documents I have to support my dispute.

I certify that the information I have provided about this matter is correct.

Signature __________________________________ Date: _________________________

Best phone number and time to reach you to discuss your dispute.

Phone: (___________) _____________________ Time: ____________________

JPMorgan Chase Bank, N.A. OH1-0553 P.O. Box 182879 Columbus, Ohio 43218-2879
Facsimile 877-875-1856