Instructions: Please make a good faith attempt to resolve a claim for a purchase directly with the merchant PRIOR to filing a disputed claim. If assistance from US Bank is required, please complete this form and fax it to PCard Administrator, Connie Oberg, 479-575-4158.
Company Name:University of Arkansas, Fayetteville
CARDHOLDER NAME:________________________________________
Account Number:_________________________________________
This Charge appeared on my statement:____________________________________
Transaction Date:________________________________________________________
Reference Number:________________________________________________________
Merchant Name/Location:__________________________________________________
Posted Amount:_____________________Disputed Amount:_______________________
Dispute Type:
_____Incorrect Charge................................................._____Credit Not Received
_____Duplicate Charge................................................._____Replacement Not Received
_____Erroneous Charge................................................._____Other
Explanation of Dispute:___________________________________________________
Merchant's Response:_____________________________________________________
Cardholder Signature:_______________________________________Date:_____________