Transaction Dispute - Checklist

TRANSACTION DISPUTE - CHECKLIST

The below checklist of items MUST BE PROVIDED in order to process the dispute request. A chargeback
specialist will be assigned to your case & contact you for further information (if necessary) and will provide
status of the submitted claim. The content provided will allow proper investigation of the transaction dispute.
Failure to provide the information in the checklist WILL PREVENT THE PROCESSING OF THE CLAIM.
This form must be received within 60 days of the date the charge posted to your account and within 10 days of
receipt of this packet.

Transaction Dispute Form

Signed Letter Describing Dispute
Copy of Receipts/Documentation
Merchant/Retail Contact Information
Cardholder Contact Information
Signed Transaction Dispute Checklist
Valid Government ID

For your convenience, there are 2 ways to submit Transaction Disputes:

Via Fax:

Via Mail:

1-855-894-1826

Incomm Inc.
c/o Chargeback Department
Post Office Box 826
Fortson, Georgia 31808-0826

Email: VRNDisputes@incomm.com
Attention: Chargeback Department
(Please Include Cover Letter)

CHECKLIST COMPLETION

12/22/15
Date: ____________
DORIS E. TIMMONS
Print Name: __________________________
Signature: (X)_________________________

INCOMM INTERNAL USE ONLY

Chargeback Specialist Signature:

Date:

I have verified that all of the required documents have been submitted before investigating this
request.

Transaction Dispute - Request Form

A.

CARDHOLDER INFORMATION

Cardholder Name:

DORIS E. TIMMONS

683182

Trouble Ticket #:

Pin Card Number

757 976 7879

798 400 6778
Address:

105 CANEY PLACE

Phone #:

912-409-7853

Phone #:
City:

State:

KINGSLAND

GA

Zip:

31548

Card Type: ATM

VISA
MasterCard
Discover
Vanilla Reload
* PayPal X**
*If dispute is in relation to a Vanilla Reload card/pin please enter 16-digit card number in which you are
attempting to reload below and refer to Sections C, E, and F ONLY:
** If dispute is in relation to a PayPal MyCash pin card, please enter the email address of the PayPal account in
which you are attempting to reload below and refer to Sections C, E, and F ONLY:

dorist@tds.net

B.

TRANSACTION INFORMATION

Transaction Type:

Point-of-Sale

Merchant Name:

CVS

Merchant Phone #:

C.

Online Transaction

ATM Withdrawal
Transaction Date:

912-729-6772

Transaction Amount:

12/13/15
$200 + $200 ea Card

TRANSACTION DISPUTE DETAILS

Please provide as much detail as possible, including the sequence of events and your attempt(s) to reconcile
with the merchant.

On Sun, 12/13/15, I purchased the 2 cards at CVS, $200 on each card. When I tried to add the $400 to my
Pay Pal acct couple days later it said cards had already been used. This was actually my first transaction and
I was very excited to shop with it. I called CVS and they said call Pay Pal. Pay Pal told me they had been used
to another Email but couldn't give me any further info.They said it is just like stealing cash and they were sorry.
Well that is how I considered it, just like I protect my money. I am glad they at least sent me to this complaint
form so pls help me. I'm attaching copy from CVS and my bank acct which shows I had just gotten the $400
from my Acct. PLEASE HELP ME.

D. RESOLUTION DETAIL
If you are due a credit/refund, how would you like to be reimbursed?
Please select one.
Credit to Card
E.

New Card Issued for Dispute Amount

Refund Check

DISPUTE AGREEMENT

Neither I nor any authorized user made or authorized the above charges on my account. I have received no
benefit from the above charges. In addition, I do not authorize any future charges to be billed by these
merchant(s) to my account.
I, the undersigned, attest that the information contained herein is true and accurate. I agree that any deception
or knowledge thereof on my part constitutes fraud and breach of contract as defined in the Cardholder
Agreement and will result in the denial of the disputed claim, and possible legal recourse/financial remuneration
as deemed necessary by InComm.

F.

CARDHOLDER SIGNATURE

12/22/15
DATE: ____________
Doris E. Timmons
PRINTED NAME: ___________________________
SIGNATURE: (X) ___________________________

FAX
To:
From:
Re:

Chargeback Department

DORIS E. TIMMONS
REF # 683182

Fax:
Date:

1-855-894-1826

12/23/15

Pages:

Cc:

X Urgent

For review

Please comment

Notes:

confidential