Dispute Resolution Form—

Pre-Compliance/Compliance

Transaction Information:

Acquirer’s Reference Data or Switch Serial Number:

     Merchant Name:      

Transaction
Amount:Transacti
on or Settlement
Date:            Disputed Amount:      

Rule Violation Cited:       Rule Violation Date:      

Dispute Information—For specific requirements for each violation, please refer to the document containing the
standard. Supporting documentation must provide sufficient detail to enable all parties to understand the nature of
the dispute. If disputing multiple transactions, the violation and PAN must be the same. Please add pages with
identification of the transactions.

Give a reasonably specific description of the dispute.

     

“The issuer certifies that it complies with Mastercard Bylaws, Rules, policies and operating regulations
and procedures of Mastercard (the “Standards”), written agreements and privacy laws and regulations
applying to the protection of personal data. The issuer agrees that the personal data collected may be
used according to Mastercard Standards and Mastercard’s Global Privacy Notice on
http://www.mastercard.us/privacy/. I certify that the facts were obtained from my discussion with
the cardholder or       , (who is the company representative or
government agency representative on behalf of the corporate card or government cardholder) and that
the facts are accurate to the best of my knowledge.”

           
1185 Page 1 of 2 Revised: September 2018
Customer Service/Chargeback Representative Date