Citibank Commercial Cards

Citibank® Commercial Cards

Cardmember Dispute Form

NAME: ______DATE: ______

ADDRESS LINE 1: ______

ADDRESS LINE 2: ______

CITY, PROV, POSTAL CODE: ______

ACCOUNT NUMBER: ______

Important: Please provide a copy of all information/forms requested below along with your statement with the disputed transaction(s) checked. This form must be filled out completely and forwarded to the Citibank Disputes Department via fax to 519-642-9780 within 60 days of the disputed charges’ posting date or we may be unable to assist you.

Please read carefully each of the following descriptions and check the one most appropriate to your particular dispute. If you have any questions, please contact us at 1-888-834-2484 (overseas call collect, 416-369-6399). We will be more than happy to advise you in this matter.

0 UNAUTHORIZED TRANSACTION – I did not authorize or sign a sales slip, nor did I authorize anyone else to make this charge.

0 DUPLICATE PROCESSING — I have been billed for the same transaction more than once. The transaction date, merchant description and location, original currency, and ticket number (if provided) are identical.

0 ADDENDUM DISPUTE – I am disputing a transaction that represents an additional charge from the same merchant where I did authorize a valid transaction (for example, an extra billing from a hotel or car rental). Provide in a separate statement the specific details concerning the dispute, your contact or attempts to contact the merchant, and the result of that contact.

0 MULTIPLE PROCESSING — I authorized a transaction on ______(date) in the amount of $______at

______(merchant name). I did not authorize the transaction on ______(date) in the amount of

$ ______at the same merchant. My card has been in my possession at all times.

0 GOODS OR SERVICES NOT PROVIDED

0 What was the expected delivery date of the goods or service? ______

0 If delivery of the goods or service was cancelled, indicate the cancellation date: ______

*Enclose on a separate sheet a reasonably specific description of the goods or services not received.

0 MERCHANDISE RETURNED

0 Merchandise was returned on ______(date). *Enclose a copy of the postal or courier receipt.

0 A credit receipt for returned merchandise has not posted to the account. *Enclose a copy of the credit receipt.

0 TRANSACTION AMOUNT DIFFERS

0 The amount of this charge has been altered since the time of purchase. The difference of amount is $______. *Enclose a copy of the sales receipt or itemized bill that confirms the amount authorized.

0 I paid for this transaction by other means. Provide proof of alternate payment. *Enclose a copy of canceled cheque (front and back), copy of other credit card statement, etc.

0 Merchant accepted a voucher from a third party. *Enclose a copy of the voucher, itinerary or receipt of payment.

0 COPY REQUEST - I recognize this charge, but need a copy of the sales draft for my records.

If none of the above reasons apply: Use a separate sheet of paper (signed and dated) to provide a complete description of the dispute, attempts to resolve with the merchant and the outstanding issues.

Cardmember Signature: ______