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CREDIT CARD CHARGEBACK REVERSAL AUTHORIZATION.

Case Number:

Transaction Date:

Visa [ ] MasterCard [ ] Discover [ ] American Express [ ] Other:

Note: The merchant, "Company Name" has obtained sufficient tracking information for this transaction and will provide a rebuttal to the credit card issuer. The merchant reserves the right to request further investigation or refer the chargeback to the proper authority should a signature from the customer not be acquired. This transaction chargeback was reported in error. I (the "Cardholder") agree to the reversal of the chargeback.

Print and Fax this form to:

Company Name Attention: Sales Dept - Fax Fax Number.

Print and mail this form to:

Company Name

City, State Postal Code

Important: Email, Adobe PDF, Email Faxes or other Electronic delivery of this form will NOT be accepted.