Dispute Instructions

Please read the following instructions carefully and fill the form attached:

Please fill a separate form for each transaction in question.

The form must be filled out in handwriting and manually signed by the cardholder.

This form must be submitted within 60 days from the time that the disputed transaction was
performed. We will contact you within 2 business days from the receipt of your documents
with further instructions and time frame for resolving your case.

Reference Number is the number associated with your correspondence with Payoneer, which
you can find in the subject line of the email (e.g 141101-000894).

Transaction Number is the unique number of the transaction you would like to dispute. You
can find it by going to www.payoneer.com and logging in to your Payoneer Account page.
Once logged in, find the transaction in your Payoneer Account transaction list and click on
it. This will open a new window with further information regarding the transaction, which
includes the "Transaction Number". The transaction date must match that of the transaction list
in the Payoneer Account.

Please note that any missing requirements may delay the dispute process.
Please provide complete details of the situation in which the card was used and the reason for your
dispute and include all supporting documentation.
The form should be sent with a scan of all supporting documents as a reply to your correspondence
with Customer Support.

Cardholder Statement of Disputed Item

Card Number: _________________________
Transaction No:________________________
Transaction Date: _____________________

Reference No: ________________________

Transaction Amount: ___________________
Merchant: ____________________________

I am disputing the above charge due to the following reason (check only one reason):
_____ I have not, nor has anyone authorized by me engaged in this transaction.
My card was lost on (date): __________
My card was stolen on (date): __________
_____ I have not authorized or participated in this transaction in any way. My card has not been out of
my possession.
_____ I have participated in one transaction at the merchant location, but NOT the transaction listed. I,
or someone authorized by me was in possession and control of all cards at the time of the
transaction. The authorized transaction amount was $ ___________ on (date) __________.
_____ I am disputing the listed ATM withdrawal. I have explained the details below.

Please provide specific details below, on back or a separate sheet of paper.

Additionally please answer the following questions:

I am familiar with the merchant who charged the transaction Y/N (circle one)
I have attempted to contact the merchant about the disputed transaction Y/N (circle one)
If Yes: Was the communication done by phone / letter / e-mail / fax / in person (circle one)
Date(s) when communication was done ________________
Describe the outcome of the communication______________________________
________________________________________________________________
Signature (handwritten): _____________________________ Date: ________________________
Phone: Day: (_____) ______________________ Evening: (_____) ________________________

In case you are disputing more than one transaction, to ensure that all dispute forms are received,
please list below the transactions you are disputing. Please note that this form below is not a dispute
form, but an additional verification of transactions disputed. A separate dispute form for each
transaction is required.
I hereby confirm that I wish to dispute the following transactions only:
Last 4 digits of the card
Name
Date
Transaction Date

Transaction Number

Transaction Amount

Signature (handwritten): _____________________________

Merchant Name