Benefits Payment Card Dispute Form

If you have a transaction on your benefits payment card that you believe should be disputed, please fill out the form below. The transaction being disputed must be less than 60 days old. If the transaction date is more than 60 days old from today’s date, the transaction cannot be disputed as it falls outside of the dispute window per Visa regulations and as provided in the Cardholder Agreement.


***NOTE: You must attempt to resolve with the merchant directly (if possible) prior to submitting the dispute.***

 
 
 
 
Phone
 
 

Details of Disputed Transaction

 
 
mm/dd/yyyy
 
 
 
 

Reason for Dispute

 

If the transaction being disputed is due to fraud, you MUST report your card as STOLEN and request a new one in order for us to proceed.

 
 
 

Please attach any receipts, proofs of payments, or any documentation that will help validate your dispute

Drop your files here