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Please complete and print this form if you are disputing a charge from a merchant that has posted to
your card. Please include a copy of all supporting documentation such as transaction receipts and
correspondence with the merchant. E m a i l t h i s f o r m a n d a n y a d d i t i on a l d o c u m e n t s t o
t r a n s a c t i o n di s p ut e @ gr e e n d o t c o r p . c o m . If you do not have access to email, please mail all
forms and any additional information in one envelope to:
Green Dot Corp. Transaction Dispute, P.O. Box 5100, Pasadena, CA 91117-0100
Preferred Phone: (
Mailing Address:
Email:
Transaction Amount: $
Date of Transaction:
Merchants Name:
Transaction # 2:
Transaction Amount: $
Merchants Name:
Date of Transaction:
Transaction # 3:
Transaction Amount: $
Date of Transaction:
Date of Transaction:
Date of Transaction:
Merchants Name:
Transaction # 4:
Transaction Amount: $
Merchants Name:
Transaction # 5:
Transaction Amount: $
Merchants Name:
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Dispute Reason:
I have not authorized this charge to my card. I have not purchased or ordered merchandise in
person, by phone, or by mail, nor have I received any goods or services from this merchant.
My card was noticed missing/lost/compromised on
Yes
.
No
, and
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Todays Date:
/
/
(mm / dd / yyyy)
Todays Date:
/
/
(mm / dd / yyyy)
Page 3 of 3