Disputed Transaction Notification Form

Important Information

This form cannot be used for disputed transactions older than 120 days or for more than £24.99.

If you are disputing more than one transaction then you must submit a form for each. If the total value of the transactions are to the same retailer and are for more than £24.99 you will need to call us.

Please tick this box to confirm you have already contacted the retailer about this transaction and have been unsuccessful in getting a refund

Your details

First name(s)*

Please enter your first name(s)

Please enter a valid first name

Last name*

Please enter your last name

Please enter a valid last name

Email address*

Please enter your email address

Please enter a valid email address

Postcode*

Please enter your postcode

Please enter a valid postcode

Last 4 Digits of your Credit Card number*

Please enter the last four digits

Amount of disputed Transaction (you can only use this form for transactions of £24.99 or less)*

Please enter your disputed amount

Please enter an amount under �24.99

Date of Disputed Transaction (date cannot be older than 120 days)*

Please enter your disputed date

Please enter a date no older than 120 days

Name of Retailer*

Please enter your retailer name(s)

Please enter a valid retailer name

Reason for Dispute*

Please select an option