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STATEMENT OF DISPUTE

RE: Case 2407030001C for account ending in 1234

I, Mr. Steve Rogers, hereby dispute the transaction(s) listed below for the following reason:

Merchandise or services not received.

I was charged for the transaction listed, but I have not received the merchandise or service. I expected to receive _____________________________________________________ from the merchant on __/_/_. I contacted the merchant on ___/_/__, and their response was ______________________________________________________________________________________________________________________________________.

Please provide any additional information you believe may be helpful in our investigation (you may attach additional pages, if needed):

___________________________________________________________________________________________________________________________________________________
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I certify that, to the best of my knowledge and belief, all the information on this statement is true, correct, complete and made in good faith.

Signature: _________________________________________________ Date: ___________________