Cardmember Services
PO Box 85800
Sioux Falls, SD 57118-5800
Thank you for your recent inquiry concerning the above referenced account number.
In an effort to assist you in resolving your dispute, please complete the enclosed dispute form
and return it to the address listed above or fax it to 1-978-367-9466.
If you have any questions, please contact Customer Service Department at 1-800-755-9203.
Sincerely,
Card Services
ACCOUNT NUMBER: _____________________________________
Merchant Name: __________________________________________
Date of Charge: ___________________Amount: $_______________
Please check and complete the statement which best applies.
_____ “Neither I nor any person authorized by me to use my card made the charge listed
above. I have received no benefits from the above charge(s). In addition, I do not authorize any
further billings from this merchant on my account.”
_____ Although I did participate in a transaction with the merchant, I was billed for ____
transaction(s) totaling $_________ that I did not engage in, nor did anyone else
authorized to use my card. I do have all of my cards in my possession.
Enclose a copy of the authorized sales slip.
_____ I have not received the merchandise which was to have been shipped to me by
_________ (mm/dd/yy). I contacted the merchant on _________ (mm/dd/yy) and
the merchant’s response was __________________________________________
_________________________________________________________________.
The merchant must be contacted for us to assist you.
_____ I have returned/cancelled (circle one) merchandise on _________ (mm/dd/yy)
because __________________________________________________________.
Please provide a copy of the postal receipt, credit slip or proof of refund.
_____ I was issued a credit slip for $_________ on _________ (mm/dd/yy) which has
not shown on my statement. Enclose a copy of the credit slip.
_____ Merchandise, which was shipped to me, arrived damaged and/or defective on
_________ (mm/dd/yy). I returned it on _________ (mm/dd/yy). The merchant’s response was
________________________________________.
Please provide a postal receipt and/or credit slip as proof of return.
_____ I was billed incorrectly for $_________ when I should have been billed $_________.
Enclose a copy of the sales slip showing the correct amount of the charge.
_____ Other – Attach a letter explaining the details of your dispute.
Signature: ___________________________________________ Date: _____________
Revvi - PO Box 85800 Sioux Falls, SD 57118-5800