Details of Disputed Transacon/s
Sr. Transacon Date Merchant Name/ATM Locaon Transacon Amount & Currency Disputed Amount & Currency
Kindly () the issue as per applicable
Duplicate/mulple billing. I have done only one transacon but I was billed ______________ (Twice/Thrice etc).
I had tried transacon online, the same was not successful but the amount was debited from my account.
Cash not dispensed in ATM but I was billed for the enre amount.
Less cash of ______________ (provide Amount & Currency) dispensed in the ATM but I was billed for the enre amount ______________
(provide Amount & Currency).
Transacon cancelled and I have not received the credit/ refund for the same (Aach credit slip/refund note/merchant’s leer or any form
of merchant’s confirmaon that the transacon was cancelled and the credit was due to you).
Paid by other means. First I gave my card for payment and later on I changed my mind and paid by other means like by cash (Aach cash
receipt/bill)/ Cheque (aach cheque receipt/bank statement)/other card (Aach chargeslip/other card statement).
Cancelled membership/Subscripon/booking (Aach the cancellaon leer which you sent to the merchant).
I ordered goods/services and the same are expected by Date (dd/mmm/yyyy) ____________. But I never received the same.
(Correspondence with merchant for order status is required)
The transacon amount is ______________ (provide Amount & Currency) but I was billed for ______________ (provide Amount & Currency).
I have not parcipated or authorized the above transacon(s). The card was in my possession at all mes.
Hotel Reservaon:
(A) I have cancelled the Reservaon. The Cancellaon Date being ______________ and the Cancellaon Code is _________
(B) I have not made or authorized any reservaon/s or availed of the services
Others (Please explain in detail. Please aach a separate leer if necessary) _____________________________________
Yes No
STD
Cardholder Dispute Form
To,
Axis Bank Ltd, NPC1, 5th Floor, "Gigaplex", Plot No I.T.5,
MIDC, Airoli Knowledge Park, Airoli, Navi Mumbai - 400708.
Fax no - 022 71315270
Axis Bank Customer
Cardholder’s Name
Contact Number
Email
Debit/Credit/Forex Card number**
Axis Bank Account Number
(Applicable For Debit Cardholders only)
I am dispung transacon/s listed above due to the following reasons. Request you to resolve the dispute.
The Goods/Services rendered by the Merchant are not as described. The item/s purchased or service/s paid for do not conform to what
was agreed to have been supplied by the merchant or was defecve. (Please specify as to what good/s or service/s were expected and
what were actually delivered. Enclose any documentaon that supports your claim. If you have returned the merchandise to the
merchant, please provide us with proof of return, such as postal/courier receipt and correspondence with the merchant.)
**Request to the Cardholder: Please aach copies of your correspondence with the Merchant, charge-slips wherever applicable and any
supplementary documents pertaining to the transacon/s, as appropriate.
Declaraon
Place ___________________________________________
Date
DDMMYYYY
Customer Signature
I hereby confirm that the averments made by me within this form are bona-fide and the informaon provided is true and accurate to
the best of my knowledge and belief. In case this claim is determined by the Bank to be false or maliciously made, I shall be fully
responsible for the consequences which may include civil/criminal lawsuit being iniated by the Bank.