HomeMy WebLinkAboutInv# PC - 15003 - BANK OF AMERICA - 11/24/2023 (2)June 2022
P-Card Statement Dispute Form
This form is provided to assist you should you believe a transaction on your statement is in error.
Regulations require that disputes be settled in 30 days, and thus should be addressed as soon as
possible.
Cardholder Name:
Vendor Name:
Transaction Date:
Transaction Amount:
Please check one of the following choices applicable to your dispute. Include all necessary
information / documentation, including a copy of the statement.
I do not recognize the above-mentioned charge.
I have been billed more than once by the same vendor. I authorized one charge with this vendor only.
Valid Charge $ ________ Reference # __________________ Transaction Date: ___________
Valid Charge $ ________ Reference # __________________ Transaction Date: ___________
I have not received the merchandise that was to be shipped to me on _____. I have requested credit.
Vendor was to issue credit for merchandise I returned to the store. I have enclosed a copy of my
credit receipt.
I have been billed for an incorrect amount. My receipt shows _______ however, I was billed _______.
I am providing a copy of my receipt showing the correct amount.
I did not authorize the above-mentioned charge. I have attempted to contact the vendor to resolve the
dispute but have been unsuccessful.
Work Phone E-mail:
Signature: Date: