Merchant Charge Dispute

CARDMEMBER DISPUTE FORM

Cards

If a transaction appears on your statement that you believe is an error and you have unable to resolve the situation with the merchant, please complete the form below. Please either fax this form to (02) 9271 1400 or mail to AMERICAN EXPRESS LIMITED, GPO BOX 1582, SYDNEY, NSW 2001. We will acknowledge receipt of your dispute claim in writing.

Please be informed that the investigation timeframe may take up to 8 weeks. A handling fee per disputed transaction may be applied if the dispute is found to be legitimately authorised by yourself or other authorised party.

Card Number:	Cardmember Name:
Address:
No./Unit: Street Name:	Suburb: State/Province:	Post/Zip Code: Country:
Contact Detail (Including area code):		Remarks:
Home: Mobile:	Work: Email:	Remark use for contacting method only. Do not exceed 5 lines.

I Wish to dispute the following transaction/s on my American Express Card:

← I wish to dispute only 1 merchant charge

← I wish to dispute 2 different merchant charges

← I wish to dispute 3 different merchant charges

← I wish to dispute 4 different merchant charges

American Express Australia Limited (ABN 92 108 952 085) ®Registered Trademark of American Express Company

	I did not recognise the merchant or authorised the transactions (nor did the additional cardmember). I do have all card/s in my possession.
	The purchase was made by other means. (Please provide either one (a) copy of cash receipt (b) the front and back of your cancelled cheque (c) copy of other bank statement as proof of payment.)
	I have been billed more than once for the same transaction. Date of original transaction was on //.
	Transaction/s incorrectly processed. I authorised only $ . (Please attach copy of valid transaction/s.)
	Credit note has not been processed or has been listed as a charge on my statement. (Please attach copy of credit note.)
	I have cancelled/attempted to cancel my arrangement for a periodic debit with the merchant on //. (Copy of the cancellation letter or instruction to the merchant to cancel the authority must be provided.)
	I have not received the goods/services ordered (mail/telephone order). The expected delivery date was //. I contacted the merchant on //. and merchant's response was: (Please specify below under additional information.)
	I attempted to cancel this purchase with the merchant on //. (Please provide the record of contact with the merchant.)
	This transaction was a cancelled preauthorised order (reservation). My cancellation number is . Date of cancellation is //. The reason I cancelled was: (Please specify below under additional information.) (If you do not have a cancellation number, please provide the contact name or a copy of your phone bill as evidence of contact with merchant.)
	Other - (Please provide details and attach any documentation available to assist in our investigations.)
Additional Information:
Do not exceed 4 lines. Highlight the word and use delete key to correct the typo error.

	I did not recognise the merchant or authorised the transactions (nor did the additional cardmember). I do have all card/s in my possession.
	The purchase was made by other means. (Please provide either one (a) copy of cash receipt (b) the front and back of your cancelled cheque (c) copy of other bank statement as proof of payment.)
	I have been billed more than once for the same transaction. Date of original transaction was on //.
	Transaction/s incorrectly processed. I authorised only $ . (Please attach copy of valid transaction/s.)
	Credit note has not been processed or has been listed as a charge on my statement. (Please attach copy of credit note.)
	I have cancelled/attempted to cancel my arrangement for a periodic debit with the merchant on //. (Copy of the cancellation letter or instruction to the merchant to cancel the authority must be provided.)
	I have not received the goods/services ordered (mail/telephone order). The expected delivery date was //. I contacted the merchant on //. and merchant's response was: (Please specify below under additional information.)
	I attempted to cancel this purchase with the merchant on //. (Please provide the record of contact with the merchant.)
	This transaction was a cancelled preauthorised order (reservation). My cancellation number is . Date of cancellation is //. The reason I cancelled was: (Please specify below under additional information.) (If you do not have a cancellation number, please provide the contact name or a copy of your phone bill as evidence of contact with merchant.)
	Other - (Please provide details and attach any documentation available to assist in our investigations.)
Additional Information:
Do not exceed 4 lines. Highlight the word and use delete key to correct the typo error.

	I did not recognise the merchant or authorised the transactions (nor did the additional cardmember). I do have all card/s in my possession.
	The purchase was made by other means. (Please provide either one (a) copy of cash receipt (b) the front and back of your cancelled cheque (c) copy of other bank statement as proof of payment.)
	I have been billed more than once for the same transaction. Date of original transaction was on //.
	Transaction/s incorrectly processed. I authorised only $ . (Please attach copy of valid transaction/s.)
	Credit note has not been processed or has been listed as a charge on my statement. (Please attach copy of credit note.)
	I have cancelled/attempted to cancel my arrangement for a periodic debit with the merchant on //. (Copy of the cancellation letter or instruction to the merchant to cancel the authority must be provided.)
	I have not received the goods/services ordered (mail/telephone order). The expected delivery date was //. I contacted the merchant on //. and merchant's response was: (Please specify below under additional information.)
	I attempted to cancel this purchase with the merchant on //. (Please provide the record of contact with the merchant.)
	This transaction was a cancelled preauthorised order (reservation). My cancellation number is . Date of cancellation is //. The reason I cancelled was: (Please specify below under additional information.) (If you do not have a cancellation number, please provide the contact name or a copy of your phone bill as evidence of contact with merchant.)
	Other - (Please provide details and attach any documentation available to assist in our investigations.)
Additional Information:
Do not exceed 4 lines. Highlight the word and use delete key to correct the typo error.

	I did not recognise the merchant or authorised the transactions (nor did the additional cardmember). I do have all card/s in my possession.
	The purchase was made by other means. (Please provide either one (a) copy of cash receipt (b) the front and back of your cancelled cheque (c) copy of other bank statement as proof of payment.)
	I have been billed more than once for the same transaction. Date of original transaction was on //.
	Transaction/s incorrectly processed. I authorised only $ . (Please attach copy of valid transaction/s.)
	Credit note has not been processed or has been listed as a charge on my statement. (Please attach copy of credit note.)
	I have cancelled/attempted to cancel my arrangement for a periodic debit with the merchant on //. (Copy of the cancellation letter or instruction to the merchant to cancel the authority must be provided.)
	I have not received the goods/services ordered (mail/telephone order). The expected delivery date was //. I contacted the merchant on //. and merchant's response was: (Please specify below under additional information.)
	I attempted to cancel this purchase with the merchant on //. (Please provide the record of contact with the merchant.)
	This transaction was a cancelled preauthorised order (reservation). My cancellation number is . Date of cancellation is //. The reason I cancelled was: (Please specify below under additional information.) (If you do not have a cancellation number, please provide the contact name or a copy of your phone bill as evidence of contact with merchant.)
	Other - (Please provide details and attach any documentation available to assist in our investigations.)
Additional Information:
Do not exceed 4 lines. Highlight the word and use delete key to correct the typo error.

	I did not recognise the merchant or authorised the transactions (nor did the additional cardmember). I do have all card/s in my possession.
	The purchase was made by other means. (Please provide either one (a) copy of cash receipt (b) the front and back of your cancelled cheque (c) copy of other bank statement as proof of payment.)
	I have been billed more than once for the same transaction. Date of original transaction was on //.
	Transaction/s incorrectly processed. I authorised only $ . (Please attach copy of valid transaction/s.)
	Credit note has not been processed or has been listed as a charge on my statement. (Please attach copy of credit note.)
	I have cancelled/attempted to cancel my arrangement for a periodic debit with the merchant on //. (Copy of the cancellation letter or instruction to the merchant to cancel the authority must be provided.)
	I have not received the goods/services ordered (mail/telephone order). The expected delivery date was //. I contacted the merchant on //. and merchant's response was: (Please specify below under additional information.)
	I attempted to cancel this purchase with the merchant on //. (Please provide the record of contact with the merchant.)
	This transaction was a cancelled preauthorised order (reservation). My cancellation number is . Date of cancellation is //. The reason I cancelled was: (Please specify below under additional information.) (If you do not have a cancellation number, please provide the contact name or a copy of your phone bill as evidence of contact with merchant.)
	Other - (Please provide details and attach any documentation available to assist in our investigations.)
Additional Information:
Do not exceed 4 lines. Highlight the word and use delete key to correct the typo error.

Basic Cardmember's Signature	Date

Basic Cardmember's Signature	Date

Basic Cardmember's Signature	Date