Are you disputing the full amount of the transaction?

Yes/No

Mandatory

What amount are you disputing?

Freeform Text

Numerical Only

Optional

When “No” to “Are you disputing the full amount of the transaction?”

What was not received?

Single Select

Merchandise

Service

Mandatory

Please provide a detailed description of what was purchased and an explanation of the dispute.

Freeform Text

Mandatory

Do you know when the merchandise was last expected to be received?

Yes/No

Mandatory

What

was the last expected receipt date for the merchandise?

Date

Conditional

When “Yes” to “Do you know when the merchandise was last expected to be received?”

Was a different date originally communicated to you?

Yes/No

Conditional

When “Yes” to “Do you know when the merchandise was last expected to be received?”

What was the original date that was communicated to you?

Date

Conditional

When “Yes” to “Was a different date originally communicated to you?”

Were you issued a credit voucher instead of a refund?

Yes/No

Mandatory

Has it been confirmed that the merchant will not honor the terms of the credit voucher or is unable to do so because they are no longer in business?

Yes/No

Conditional

When “Yes” to “Were you issued a credit voucher instead of a refund?”

Please explain.

Freeform Text

Conditional

When “Yes” to “Has it been confirmed that the merchant will not honor the terms of the credit voucher or is unable to do so because they are no longer in business?”

Has it been confirmed that the merchant will not provide the merchandise/services? (ie. Merchant is no longer in business)

Yes/No

Conditional

When “No” to “Were you issued a credit voucher instead of a refund?”

Please explain.

Freeform Text

Conditional

When “Yes” to “Has it been confirmed that the merchant will not provide the merchandise/services? (ie. Merchant is no longer in business)”

Is the dispute regarding delayed delivery?

Yes/No

Mandatory

Is the dispute regarding a merchant pre-paid gift card?

Yes/No

Mandatory

Does the pre-paid gift card have a expiration date?

Yes/No

Conditional

When “Yes” to “Is the dispute regarding a merchant pre-paid gift card?”

What is the expiration date?

Date

Conditional

When “Yes” to “Does the pre-paid gift card have a expiration date?”

Did you attempt to resolve with the merchant?

Yes/No

Mandatory

Please explain.

Freeform Text

Conditional

When “Yes” to “Are there local laws or regulations prohibiting you from resolving with the merchant?”

Do you have any additional information

that should be provided to the merchant regarding your dispute?

Yes/No

Mandatory

Please provide any additional information. This will be provided to the merchant.

Freeform Text

Conditional

When “Yes” to “Do you have any additional information that should be provided to the merchant regarding your dispute?”

Do you know when the service was last expected to be performed?

Yes/No

Mandatory

When was the service last expected to be performed?

Date

Conditional

When “Yes” to “Do you know when the service was last expected to be performed?”

Was a different date originally communicated to you?

Yes/No

Conditional

When “Yes” to “Do you know when the service was last expected to be performed?”

What was the original date that was communicated to you?

Date

Conditional

When “Yes” to “Was a different date originally communicated to you?”

Were you issued a credit voucher instead of a refund?

Yes/No

Mandatory

Has it been confirmed that the merchant will not honor the terms of the credit voucher or is unable to do so because they are no longer in business?

Yes/No

Conditional

When “Yes” to “Were you issued a credit voucher instead of a refund?”

Please explain.

Freeform Text

Conditional

When “Yes” to “Has it been confirmed that the merchant will not honor the terms of the credit voucher or is unable to do so because they are no longer in business?”

Has it been confirmed that the merchant will not provide the merchandise/services? (ie.

Merchant is no longer in business)

Yes/No

Conditional

When “No” to “Were you issued a credit voucher instead of a refund?”

Please explain.

Freeform Text

Conditional

When “Yes” to “Has it been confirmed that the merchant will not provide the merchandise/services? (ie. Merchant is no longer in business)”

Is the dispute regarding delayed delivery?

Yes/No

Mandatory

Is the dispute regarding an interruption of an ongoing service?

Yes/No

Mandatory

When did the interruption of the service occur?

Date

Conditional

When “Yes” to “Is the dispute regarding an interruption of an ongoing service?”

Did you attempt to resolve with the merchant?

Yes/No

Mandatory

Please explain.

Freeform Text

Conditional

When “Yes” to “Are there local laws or regulations prohibiting you from resolving with the merchant?”

Do you have any additional information that should be provided to the merchant regarding your dispute?

Yes/No

Mandatory

Please provide any additional information. This will be provided to the merchant.

Freeform Text

Conditional

When “Yes” to “Do you have any additional information that should be provided to the merchant regarding your dispute?”