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: theteam@onepay.co.uk If you have any questions, please call 01133 201 900.

Full Name:
Address:

Date of Birth:

Email:
Mobile No:
Card No:

Home Phone:
4

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 to
try 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 services
on___ / ___ / ___. 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 been
received, 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:

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