Return Address |
Enter your campus address where you can be reached during the day for an necessary inquiries or you would like a notice sent once the issue has been researched and resolved. This may be the address of a department support person, if you are not generally available to answer these questions. |
Phone No. |
Enter your phone number. |
FAX No. |
Enter your FAX number. |
Account No. |
Enter your account number from your purchasing card. |
Merchant Name |
Enter the name of the merchant with whom you have the disputed charge. This should be on your invoice or receipt, or on the detail transaction in HUM or CUFS. |
Amount |
Enter the amount of the disputed transaction in total. If you are disputing only part of the amount, indicate that in the appropriate location below. |
Transaction Date |
Enter the date the transaction occurred. This would be the date on the invoice or receipt, or the transaction date from the HUM table. |
Reference # |
Enter the bank's reference number for this transaction. The last few digits are available on the CUFS PV document in CUFS, but the entire number is available in HUM or on your monthly statement. |
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Read the following options, and place an check mark in the space beside the one that most closely meets your particular circumstances.
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If you did not make the charge |
Enter a check mark in the space in the left column. Then indicate where your card currently is located. This is attempting to ascertain that the card is not lost or stolen. |
If there is a difference between what you are billed and what your receipt says |
Enter a check mark in the space in the left column. Make a copy of your receipt or invoice and attach it to this form. |
If you have been billed more than once for the same charge |
Enter a check mark in the space in the left column. |
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Enter the date the first billing occurred. This is available from within the HUM database or from your monthly statement. |
If the transaction is yours, but you have a problem with the amount or goods |
Enter a check mark in the space in the left column. Enter a brief description of what the problem is, and what steps you have taken to resolve the problem |
If you need a copy of the original receipt that you signed. |
Enter a check mark in the space in the left column. This will have a charge associated with it. You will need to identify the source of the funds for this charge, or it will be charged against your default account for your purchasing card. Typically, this will not be acceptable as supporting documentation by itself. |
If you have received a credit from the supplier, but it has not been credited to your account |
Enter a check mark in the space in the left column. Make a copy of the credit you have received from the supplier. Attach the copy to this form for the bank to research. |
If you have been charged for something you have ordered but have not yet received |
Enter a check mark in the space in the left column. Briefly describe what you have done to resolve this issue with the supplier. |
If you have been charged for something you have already returned. |
Enter a check mark in the space in the left column. Make a copy of the postage receipt you received when returning the goods to the supplier. Attach the copy of the receipt to this document. If you received a Return Authorization number from the supplier to return the goods, make a note of the number on this form at the bottom. |
Space for additional information regarding your claim. |
Signature |
This must be signed by the authorized cardholder. |
Date |
Today's date. |
When complete, send the original to the address on the bottom of the form and send a copy to your account manager for their records. You should receive a response from the bank directly as to the status of your request. |