Numi Financial
Cardholder Dispute Form
This form has been provided for your convenience. If you believe that a transaction/s on your account is in error you can
use this form to dispute the transaction/s in question.
Please complete and mail or fax a copy of this form along with any supporting documentation to Card Services, ATTN:
Dispute Dept., PO Box 543000 Omaha, NE 68154, or Fax to 917-979-2032.
PLEASE DO NOT ALTER THE WORDING ON THIS FORM
Personal Information (Please fill this section out completely. Failure to do so will result in a delay of your claim
resolution)
George christou
Your Name: _____________________________ 5285170140288750
Account Number: ________________________
(16 Digit Card Number)
5093705362
Telephone: ______________________________Best 2pm-8pm
time to call: _________________________
1475 venetian dr sw
Address Line 1: __________________________________________________________________
Address Line 2: __________________________________________________________________
Atlanta
City: ______________________________
State: ______________________________
Georgia
30311
Zip Code: __________________________
[email protected]
Email Address (optional): _______________________________________________
Transaction Information (please refer to your statement for assistance)
Transaction Date: _______________________
06/27/2024 06/27/2025
Posting Date: ___________________
Amount $: _____________________________Disputed
$200.00 $200.00
Amount $:______________
Atm link
Merchant Name: ________________________Reference Number: ______________
4183 sequence number
Disputing more than one item? Yes ___ No X
____
Select Type of Dispute (Check only one)
⧠ Charged twice for the same transaction – I certify that the charge in question was a single transaction, but was
charged twice to my account. I did not authorize the second transaction.
Sale # 1 (Valid Transaction) $________________ Reference #: ______________
Sale # 2 (Invalid Transaction) $________________ Reference #: ______________
⧠ Cancellation (hotel, good, services, ..) – Please enclose copy of letter, email, or fax informing the merchant of
cancellation.
Date of cancellation ________________ Cancellation # _________________________
Reason for cancellation? __________________________________________________
⧠ Merchandise was returned - Please attach signed copy of proof of return.
Reason for returning ______________________________________________________
If you are unable to return the merchandise, please explain
________________________________________________________________________
⧠ Merchandise not received - Please notify the merchant of non-receipt.
I have not received merchandise that was to be shipped or picked up on (mm/dd/yy) ____/____/____
I have asked the merchant to credit my account No ____ Yes ____
If Yes, when? ____/____/____
⧠ Merchandise shipped was either damaged or defective - You must explain in detail how the merchandise was
damaged or defective, provide proof and attempt to return the merchandise prior to exercising this right.
I have asked the merchant for a credit to my account No ____ Yes ____
If Yes, when? ____/____/____
⧠ Overcharged for a transaction - Please include a copy of the signed sales receipt.
The amount was increased from $ _____ to $ _____
⧠ Credit posted as a sale - Please attach a copy of the credit slip and the original sales slip.
⧠ Credit not posted to account - Please enclose a copy of the credit slip or notice of credit from the merchant
and a detailed explanation of your dispute. The merchant has 30 days to credit your account.
⧠ Transaction paid by other means - You must provide proof of paid by other means such as a copy of
the cancelled check (front and back), a cash receipt, or a statement from another credit/debit card account.
⧠ ATM (Partial dispensed)
I made attempt/s and did not get the full amount
Amount Charged: __________ Amount Dispensed: __________
⧠ ATM (Non dispensed)
$200.00
Requested amount __________
⧠ Unauthorized charge - I certify that I did not authorize or participate in this transaction with the above-mentioned
merchant, nor did I authorize anyone else to use my card. To use this option, you must report your card
lost or stolen immediately.
Please provide additional details:
1. Date card was lost or stolen ________________________
2. Where do you store your PIN? ______________________
If you are disputing more than one transaction please use the space below:
DATE AMOUNT DESCRIPTION (Merchant Name) REFERENCE NUMBER
⧠ Other - Please enclose a DETAILED description on a SEPARATE SHEET and attach it to this form.
SIGNATURE REQUIRED _________________________________ 06/30/2024
DATE_____________
Please keep the original for your records
