Unauthorized Family Member Purchase Billing Dispute Form
Use this form to report a purchase made by a family member that you did not authorize and to request review of the disputed billing. Please provide the account details, transaction information, and your preferred resolution.
Account Holder Information
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing ZIP / Postal Code
Disputed Purchase Details
Date of Disputed Purchase
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Merchant / Store Name
*
Transaction Amount
*
Last 4 Digits of Payment Card
*
Dispute Explanation and Resolution
Family Member Name or Relationship
*
Explanation of Why the Charge Was Unauthorized
*
Requested Resolution
*
Refund
Charge Reversal
Investigation
Other
Submit Dispute
Should be Empty: