Cardmember Dispute Form - 2019 - Required Information

Sep 16, 2026

Cardmember Dispute Form for 2019 provides a structured way to report disputed card transactions to American Express. It captures card number, statement date, sale date, merchant name, amount, and the specific dispute reason, including requests for more information, suspected fraud certifications, processing errors requiring supporting documents, and disagreements about goods, refunds, subscriptions, or additional charges. The form also lists required document types and includes a declaration section for the cardmember’s confirmation, name, and signature, plus submission options.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Cardmember Dispute Form

Disputed Charge Details

Reason for Review

Required Documents

Declaration and Submission

CARDMEMBER DISPUTE FORM | Card Number: | 3 | 7 | | | X | X | X | X | X | X | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | A) DISPUTED CHARGE DETAILS: As shown on statement dated | Sale Date | Merchant Name | Amount | Remarks | | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | | | | | | | B) REASON FOR REVIEW a. I need more information regarding the above transactions (Standard Enquiry) I remember similar transaction(s) but could not remember transacting with the above Merchant. I agree with the transaction. I need copies for my personal records but fully aware that the merchant may not provide document. b. I’m not aware of the transaction and I did not transact with the Merchant\Outlet (Suspected Fraud) I certify that the charge(s) listed above have NOT been incurred by me nor have I received any goods or services I certify that I did not try to withdraw money in an ATM machine. I certify that the Card is in my possession and never lost or stolen I certify that the Card was never received and/or activated I certify that the Card was lost or stolen and reported to American Express® on (date and time) NOTE: As we investigate this case, we may temporarily block your Card and issue a Replacement Card. We may contact you and request more information if needed. You may be required to fill out, sign and return an official Fraud Declaration Form. c. I do not agree with the transaction (Processing Error- *Required Documents \#1 & 2) The amount charged is incorrect. I was charged for (amount) but I should have been charged for (amount) . I have been billed more than once for the charge (duplicate charge) . I have authorized only (number) for (amount) . I have not incurred the above charge(s) but I only engaged in a transaction for (amount) on (date) . I have settled the charge directly with the Merchant through Cash / Cheque / Other (Circle One & Specify) . I tried to withdraw cash from ATM, but no cash was dispensed. d. I do not agree with the transaction (Cardmember Disagreement- *Required Documents \#1, 2, 3 & 4) The Merchant did not process Credit/Refund as agreed. The received goods/services are not as agreed with the Merchant. I expected to receive goods/services on (date) from the Merchant but the goods/services have never been received. I returned the receive goods/services on (date) but the Merchant refused to accept it and/or no refund was given. I cancelled the subscription/membership/reservation against the above charge(s) on (date) . I disagree with the additional charges from above Merchant. Others (Please Specify) ~~ ~~ *REQUIRED DOCUMENTS (Please provide as much as possible) 1. Copy of disputed contract/reservation/receipt/invoice given by Merchant including return/cancellation policies. 2. Copy of “proof of payment” like signed slip (American Express or other Cards), cash receipt, cheque or others. 3. Attach brief description of the problem and details of Merchant (contact person, position, Telephone \#, date of contact, etc. ) 4. Copy of communication between you and Merchant requesting for refund/credit to resolve the disagreement. DECLARATION I hereby affirm that the information provided above is true to the best of my knowledge. I am also mindful that the merchant may not allow me to transact with them in the future as a consequence of raising this dispute with American Express. Cardmember Name Cardmember Signature | Email Address: | Contact Number: | | --- | --- | | You can submit your signed form along with the supporting documents to us through any of the following options:
• Dropping off your form and the documents to your nearest AMEX (Middle East) B.S.C. (c) local office
• Emailing scanned copies of your form and documents to us by email or sending us fax at:
Customer Services: [tsc@america

FAQs

What information must be filled in under Disputed Charge Details?

Provide the statement date and the disputed sale details including sale date, merchant name, and amount.

What options are available for submitting the completed dispute form?

Submit the signed form and supporting documents by dropping off at the nearest AMEX local office or by emailing scanned copies or faxing to the listed American Express contact emails and numbers.

What documents are required if the dispute is a processing error or a cardmember disagreement?

Processing errors require the disputed contract/reservation/receipt/invoice, proof of payment, and a description of the problem and merchant details; cardmember disagreements additionally require communication requesting a refund/credit and other relevant proof as specified.

Sep 16, 2026

Uploaded by Arica Lee