Louisiana: Cardholder Disputed Item Statement

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Member Information

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Home Phone*

Work Phone*

Member Account Number*

Dispute Information

Type of Dispute*

Credit Card Dispute Debit Card Dispute

Card Number*

Type of Loss*

My card was lost. My card was stolen. My card was in my possession at the time the transaction(s) occurred.

Transaction Information

I have examined the charges on my account and question the following transaction(s).

Merchant Name #1

Amount #1 $

Transaction Date #1

Merchant Name #2

Amount #2 $

Transaction Date #2

Merchant Name #3

Amount #3 $

Transaction Date #3

Merchant Name #4

Amount #4 $

Transaction Date #4

Merchant Name #5

Amount #5 $

Transaction Date #5

Do you need to dispute more than five items?

Yes No

You can dispute up to 20 items with this form.

Merchant Name #6

Amount #6 $

Transaction Date #6

Merchant Name #7

Amount #7 $

Transaction Date #7

Merchant Name #8

Amount #8 $

Transaction Date #8

Merchant Name #9

Amount #9 $

Transaction Date #9

Merchant Name #10

Amount #10 $

Transaction Date #10

Merchant Name #11

Amount #11 $

Transaction Date #11

Merchant Name #12

Amount #12 $

Transaction Date #12

Merchant Name #13

Amount #13 $

Transaction Date #13

Merchant Name #14

Amount #14 $

Transaction Date #14

Merchant Name

Amount #15 $

Transaction Date #15

Merchant Name #16

Amount #16 $

Transaction Date #16

Merchant Name #17

Amount #17 $

Transaction Date #17

Merchant Name #18

Amount #18 $

Transaction Date #18

Merchant Name #19

Amount #19 $

Transaction Date #19

Merchant Name #20

Amount #20 $

Transaction Date #20

Attempt to Resolve Information

In dispute cases except those related to lost/stolen/counterfeit cards, you are required to make an attempt to resolve the dispute with the merchant prior to filing a dispute. Please describe your attempt to resolve in the following section.

I have made an attempt to resolve with the merchant.*

Yes No

Date of Contact*

Contact Method*

Telephone Email In-Person

Other:

Merchant's Response*

Details of dispute and/or additional comments.

Authorization

Cardholder Signature*

[clear]

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Date*

Member Information

Dispute Information

Transaction Information

Dispute Description

Attempt to Resolve Information

Authorization