DISPUTED TRANSACTION FORM
PART Α: Please fill in ALL fields below in BLOCK CAPITALS
Cardholder’s Name & Surname
Card Number
Please select the most appropriate: Card was in my possession at the time of the transaction
Card was Lost / Stolen
PART B: Disputed Transaction Details
If you are disputing more than seven (7) transactions, please provide the transaction details on a separate sheet.
Transaction Amount
Transaction Date Merchant Name
(in transaction currency)
_____/_____/_______ ____________________________________________________ ___________________
_____/_____/_______ ____________________________________________________ ___________________
_____/_____/_______ ____________________________________________________ ___________________
_____/_____/_______ ____________________________________________________ ___________________
_____/_____/_______ ____________________________________________________ ___________________
_____/_____/_______ ____________________________________________________ ___________________
_____/_____/_______ ____________________________________________________ ___________________
PART C: Disputed Transaction Reasons
Please select the most appropriate reason for the dispute:
1. FRAUDULENT TRANSACTION(S)
I never authorised or participated in any of the transactions listed above/marked with an asterisk on the attached
separate sheet.
2. GOODS OR SERVICES NOT RECEIVED OR AS DESCRIBED
I have attempted to contact the merchant but I have been unsuccessful in resolving the dispute with them.
I authorised these transactions but the goods/services:
Were not received.
Were not as described and were returned to merchant/cancelled. YES NO (select applicable)
Were faulty and were returned to merchant/cancelled. YES NO (select applicable)
Were previously cancelled.
I provide the following relevant documentation to support the above claim:
Copy of original invoice/contract to explain goods/services ordered.
Terms & Conditions of purchase.
Copy of all correspondence with supplier/service provider.
Proof that goods were returned to supplier.
3. ATM CASH NOT RECEIVED / INCORRECT CASH DISPENSED
I have received some / none of the cash requested. Amount requested was _______________________________
the amount received was ______________________.
4. PAID BY OTHER MEANS
I paid the merchant by _________________________________________ (method of payment), but this transaction
was also debited to my card. I have contacted or attempted to contact the merchant to resolve the dispute and the
merchant refused to refund.
I have enclosed proof of payment (e.g. cash receipt, other card receipt)
5. REFUND NOT PROCESSED
The merchant agreed to refund the card with the amount of _______________________________ but no refund has
been processed. I have enclosed a copy of the refund voucher or letter/email from the merchant confirming a refund is
due.
6. RECURRING TRANSACTION
I have previously cancelled the transaction payment with the merchant _________________________________
(name) on ______/______/________ (date). (If you have proof of cancellation please provide copies)
7. SAME PURCHASE CHARGED TWO OR MORE TIMES
My account has been charged ___________ (number) times. Only ___________ (number) of these transactions were
authorised by me. (If you have any relevant documentation to support this please provide copies)
8. TRANSACTION AMOUNT IS INCORRECT
The amount I authorised differs from the amount charged to my account. I have enclosed a copy of the sales
vouchers/invoice or other proof, that the amount charged is incorrect.
9. ONLY AUTHORISED ONE TRANSACTION
I authorised one transaction with the merchant for_________________________ (transaction currency & amount) but
not for __________________________ (transaction currency & amount). My card was in my possession when the
disputed transaction(s) took place. (Please enclose a copy of the sales voucher, if you have it)
10. OTHER
My dispute does not fall into one of these categories.
(Please give a full explanation regarding this dispute below, enclosing any documentation to support it. If you require
more space, provide it on a separate sheet and attach it to this form)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PART D: Declaration
I hereby confirm that the information provided is true to the best of my knowledge.
Cardholder’s Signature: Date: _____/_____/_____
Completed form, together with the required documents, to be returned to Hellenic Bank Public Company Ltd,
Card Services Fraud & Chargebacks, by email to cardservices.fraud@hellenicbank.com or by hand to any Hellenic
Bank Branch.
CS(CD)56 v.1.3 - 08/2022 ‘CONFIDENTIAL when completed’ Page 1 of 2 YK002
