Signed written statement supporting a credit or debit card chargeback dispute, documenting unauthorized charges, non-delivery, or misrepresented goods and services under the Fair Credit Billing Act (15 U.S.C. § 1666) and Regulation Z.
The Chargeback / Payment Dispute Statement is a ready-to-use retail & consumer template you can send for signature in minutes. It is written for 1 signer (cardholder) and, by default, expires 30 days after it is sent if left unsigned. It covers chargeback, dispute, fcba, credit card, payment dispute, fraud. Like every Abundera Sign template it is a convenience draft structured for ESIGN Act and UETA compliance, not a substitute for legal advice. Each signed copy is sealed with PAdES-LTA digital signatures, dual RFC 3161 timestamps, and a tamper-evident evidence package in WORM storage.
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# Chargeback / Payment Dispute Statement This statement supports a formal billing dispute submitted pursuant to the Fair Credit Billing Act (FCBA), 15 U.S.C. § 1666 et seq., and Regulation Z, 12 C.F.R. § 1026.13. For credit card disputes under the FCBA, **written notice must be sent to your card issuer within 60 days of the first statement on which the disputed charge appeared.** For debit card disputes, the Electronic Fund Transfer Act (EFTA), 15 U.S.C. § 1693f, and Regulation E, 12 C.F.R. § 1005.11, apply with different timelines. Submit this statement to your card issuer's billing disputes address, not the general customer service address. --- ## Cardholder Information Full Name: ___________ Billing Address on Account: ___________ Phone Number: ___________ Email Address: ___________ --- ## Card and Account Information Card Type: ___________ Last Four Digits of Card Number: ___________ Card Issuer / Bank Name: ___________ Account Number (last 4 digits, if different from card): ___________ --- ## Disputed Transaction(s) **Transaction 1** Merchant Name: ___________ Transaction Date: ___________ Transaction Amount: ___________