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 UMB is required, please complete this form and fax it to Credit Card Administrator, Connie Oberg, 479-575-4158.

University of Arkansas Disputed Item Form for TCard

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:___________________________________________________