Contract and Transaction Dispute Checklist

Transaction Dispute - Checklist

TRANSACTION DISPUTE - CHECKLIST
The below checklist of items MUST BE PROVIDED in order to process the dispute request. A chargeback specialist will be assigned to your case & contact you for further information (if necessary) and will provide status of the submitted claim. The content provided will allow proper investigation of the transaction dispute.
Failure to provide the information in the checklist WILL PREVENT THE PROCESSING OF THE CLAIM.
This form must be received within 60 days of the date the charge posted to your account and within 10 days of receipt of this packet.
Transaction Dispute Form
Signed Letter Describing Dispute
Copy of Receipts/Documentation
Merchant/Retail Contact Information
Cardholder Contact Information
Signed Transaction Dispute Checklist
Valid Government ID

For your convenience, there are 3 ways to submit Transaction Disputes:
Via Mail:
Incomm Inc. c/o Chargeback Department
Post Office Box 826
Fortson, Georgia 31808-0826

Via Fax:
1-855-894-1826
Attention: Chargeback Department
(Please Include Cover Letter)

Via Email:
[e-mail]

CHECKLIST COMPLETION
Date: ____________

Print Name: __________________________

Signature: (X)_________________________

INCOMM INTERNAL USE ONLY
Chargeback Specialist Signature:

Date:

I have verified that all of the required documents have been submitted before investigating this request. Transaction Dispute - Request Form
A.

CARDHOLDER INFORMATION

Cardholder Name:

Trouble Ticket #:

16-digit Card Number:

Address:

Phone #:
Phone #:

City:

State:

Zip:

Card Type: ATM
VISA
MasterCard
Discover
Vanilla Reload
*
*If dispute is in relation to a Vanilla Reload card/pin please enter 16-digit card number in which you are attempting to reload below and refer to Sections C, E, and F ONLY:

B.

TRANSACTION INFORMATION

Transaction Type:

Point-of-Sale

Online Transaction

ATM Withdrawal

Merchant Name:

Transaction Date:

Merchant Phone #:

Transaction Amount: