Cardholder Dispute Form.

To, The Chargeback Unit, AXIS Bank, ACC - Retail Business Processes Dept, Solaris, C-Wings, 9th Floor, Opp L&T Gate no.6 Saki Vihar Road, Powai, Mumbai 400 072 Fax - 91-22-4075 3556.

Debit Card Number:

Account Number: Details of Disputed Transaction:

Sr. No. Transaction Date Merchant Name/ ATM Location Transaction Amount Disputed Amount

I am disputing the transaction(s)* listed above for the above for the below given reasons and request you to settle the cases. Duplicate/ multiple billing. I have done only one transaction but I was billed (Twice/ Thrice etc). I had tried transaction online, the same was not successful but the amount was debited from my account. Cash not dispensed in ATM but I was billed for the entire amount. Less cash Rs. Dispensed in the ATM but I was billed for the entire amount Rs. . Transaction cancelled and I have not received the credit/ refund for the same (Attach credit slip/refund note/ merchants letter or any form of merchants letter or any form of merchants confirmation that the transaction was cancelled and the credit was due to you). Paid by other means. First I gave my card for payment and later on I changed my mind and paid by other means like by cash (attach cash receipt/bill)/ Cheque (attach cheque receipt/bank statement)/other card (attach chargeslip/other card statement). Cancelled membership/Subscription/booking (Attach the cancellation letter which you sent to the merchant). I ordered goods/services and the same are expected by Date (dd/mm/yy). . But I never received the same. The transaction amount is Rs. but I was billed for Rs. . . I have not participated or authorized the above transaction(s). The card was in possession of mine at all times. Others (Please explain in detail. Please attach a separate letter if necessary) Declaration: I hereby confirm that the information mentioned above is true and to the best of my knowledge. Cardholders Name: Signature: Email: Place: Date: Phone: