Payment Dispute/Review Request This form is intended for customers that are disputing a payment or requesting additional information in regards to a payment. If you are a merchant, please contact the helpdesk. Please complete as much of this form as you can. This will make tracking down a payment faster, to provide a quick solution.Payment Request Type *Select oneCharge/Payment DisputeMissing PaymentRefund of PaymentOtherFraud ChargeSelect what type of request this isPayer First Name *First name of payerPayer Last Name *Last name of payerEmail Address *Phone *Merchant *Select MerchantJeffrey Has Heart (JHH)The Homestead at 3218ShureNET InternetWhispering Oaks Campground & RetreatZynimus CompanyOtherSelect the merchant where the payment was madeHave you contacted the merchant about this paymentYesNoWas a mutual agreement reached or setteled?YesNoNotice:If you have not contacted the merchant about a refund or agreement, we will refer you to that merchant. If this is a fraud charge, please continue, you will not need to contact the merchant.What is the desired outcome? *RefundCredit to my accountCharge BackMerchant ComplaintOtherPayment InformationName on cardEnter the name on the card used to make the payment.Last 4 digits of card numberWhat are the last four digits are the card used to make this payment?0 / 4Other InformationAdditional Information *Submit Dispute
