Form : CDF 1

Credit Cards Dispute Form

Customer’s Information
Cardholder Name

National ID or Iqama number –

Account Number

CIC

Telephone

Mobile

Card Number (please write the first 6 and

the last 4 numbers only )
X X X X X X 4 6
Dispute transaction information
Transaction details Transaction 4 Transaction 3 Transaction 2 Transaction 1
Merchant Name

Amount

Date

Dispute No. with notes if any.

Choose the dispute description number from the list below then fill in the above.
Dispute description No.
Transaction not Recognized (Merchant /Date/Amount/Location) 1
Not Participated or Authorized. Card was in my possession the time of 2
transaction
Unauthorized Internet / Mail Order/Telephone order, (Note: your card will be 3
blocked / Closed and new card will be reissued)
Debit Instead of Credit (Incorrect Transaction Type) 4
Cash not dispensed from ATM 5
Partial cash not dispensed from ATM 6
Multiple Billing # Times (…..…) 7 ..…
Proof documents required for below disputes, please attach the requested
documents:
Amount Altered from (………….) to (……..….) 8 …….…… ………..…
Paid By other means 9
Cancelled Recurring Subscription on (…… …..…) 10 ……
Returned Merchandise / Cancelled Service 11 /
Not as described or defective merchandize 12
Credit Refund/ Not Received/ Void Transaction 13
Cancelled the transaction on / / with cancellation Code (……….) 14
Not Received goods / Services Expected by (…………….) 15
Others: Please Specify 16

Provide Additional Information

Declaration: I herby affirm that the information furnished is true to the best of my
knowledge and agree to be charged as applicable in case the transaction is proved
to be genuine.

Customer Signature
____________________ 906

Please fill in the form and fax it to Fax No: +96614600705