Dispute Declaration Form
Please fill in all the details and send the completed form along with supporting documents to
disputeresolution@cosmopayment.com
Name and Address of Cardholder:
First Name: ………………………………………………...
Surname: …………………………………………...………….
Address: ………………………………………………………………………………………
City: …………… Country: …………………… Postal code: ………………………...
Email Address: ……………………………………………………………………………......
Last 4 Digits of Prepaid Card: ………………………………………………………………
SAN No (9 digits number behind the card): ………………………………………………….
Is The Card Still in Your Possession (please circle)? Yes No
Disputed transaction details:
Transaction date & Transaction amount Merchant name & Transaction ID
time location
To assist our investigation, please indicate below the reason for your dispute (please tick):
□ I neither made, colluded in, nor authorised, the above transaction(s)
□ There is a difference in the amount I authorised and the amount I was charged.
□ This is a duplicate transaction(s), I authorised only one transaction(s) and it was previously
charged to my account on ……………………………………
□ Goods or services not received.
□ I attempted to withdraw the amount from an ATM but no funds were dispensed but have
debited my account
□ Other – Please provide full details of the dispute along with necessary proofs.
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Please include any further information/proofs which you think may assist us with our
investigation.
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I …………………………………………, confirm to the best of my knowledge and belief, the information
supplied on this form is correct and complete. After our investigation if it is found that the
above transactions have been falsely reported we hold the right to debit your card for any
financial loss incurred by us. We also have the right to report you to the police or other
financial crime agencies for further prosecution if false reporting has occurred. I also
understand that these details may be used as evidence in the event of any police enquiry or
court hearing.
In addition, you agree that fees of up to 20 EUR per transaction (volume dependent) will be
charged.
Signed……………………………………………...…
Dated……………………………
