MPESA-Card-Dispute-Form

M-PESA GlobalPay

Contact Number

Email Address

Dispute Date

Amount (KES)

Transaction ID

Merchant Name

Please select one option below.

I did not perform/ was not aware of this transaction.

The card was used twice, only one of the transactions were successful, one transaction failed. The funds were deducted twice.

I used the card but the transaction was unsuccessful. The funds were deducted. I used other means of payment.
(please attach declined slip if available)

(Only 5mbs or less of types pdf, png and jpg files are accepted)

Goods/Services were not received (Please attach decline slip if available)

(Only 5mbs or less of types pdf, png and jpg files are accepted)

1) Did you cancel the order prior to the delivery date of the goods/service?

Yes No

Did you try to resolve the dispute with the merchant?

Yes No

If Yes, when did you attempt and why did the merchant fail to resolve the dispute

If No, what are the reasons?

Please provide additional information/details if available.

Declaration

I hereby confirm that

I did not authorise any person to effect the said transaction(s) on my behalf.
I received no benefit from the proceeds of the said transaction(s).
I am aware that Safaricom (issuing bank), will be taking action based on the contents of this statement.
This statement is accurate and complete.
I am also aware that investigations of disputed card transactions take up to 45 business days to complete.

I hereby indemnify you, your employees or agents against any claim, loss or damages, both direct and indirect, which may arise as a result of actions taken based on the information provided in this statement.

Full Name