State of Connecticut P-Card Transaction DISPUTE FORM

File this claim with the JPMorgan Chase Disputes Team:

Call 1-800-316-6056 (the number on the back of the card) or

Email this form to ccscolumbusdisputes@chase.com

Attn:	Date:

JPMorgan Chase Disputes Team	# of pages including this page:

I am initiating this dispute on behalf of the customer, State of Connecticut,

Corp. # 6130

Name:	Relationship to cardholder:

Phone #:	Fax #:

Signature:

Cardholder Information (only the last 8 digits of the account number)

Account Number: x x x x - x x x x - _ _ _ _ - _ _ _ _

Cardholder Name: ______	Phone #:

Agency:

Transaction Information

Merchant Name:	Phone #:

Merchant Location:

Transaction Date: _ _ / _ _ / _ _	Transaction Amount $

Please check the appropriate dispute and complete the corresponding information.

I don’t recognize this sale.

I never authorized this transaction.

**Cardholder Signature required:

This transaction appears twice on my statement, and I only authorized one transaction. **Cardholder Signature required:

I paid for this transaction by other means.

**Must provide supportive documentation as proof of payment.

I was billed a different amount than my receipt shows.

**Must provide a copy of the receipt showing the amount that should be billed.

Other: