New Transaction Dispute Form

Cardholder Details

Full Name:

Phone Number:

Email Address:

Card Number:

Transaction Amount in Birr:

Dispute Details

Please select the reason for your dispute:

I require more details regarding the transaction
I confirm that neither I nor any additional cardholder authorized the transaction
I tried to withdraw cash from ATM, but no cash was dispensed
I withdrew Birr but received less

I authorized a transaction on this date, but it was duplicated

The goods were returned, but no refund was issued

Other (please specify)

Declaration

I declare that all information provided is true.

Signature:

Date: