Subject: Chargeback request

Place and date:
Credit card issuer’s name:
Credit card issuer’s address:
 

Hello,

Section 54.14 of Québec’s Consumer Protection Act provides that I can file a request that you chargeback all amounts paid by credit card in relation to the purchase described below.

Credit cardholder’s name:

Credit card number:

Credit card expiry date:

Merchant’s name:

Amount charged to the credit card that should have been reimbursed by this merchant:

Date of the purchase:

Description of the goods or services purchased:

Reason for cancelling the purchase:

Date on which the cancellation notice was sent to the merchant:

Means used to send the cancellation notice to the merchant:

Under section 54.16 of the Act, you are required to:

• send me an acknowledgement of receipt within 30 days after receiving this request;
• chargeback my account for the amount paid and cancel all credit card charges in connection with the purchase by whichever of the following deadlines comes first:
  • no later than 90 days after receiving this request,
  • within 2 complete account statement periods.

Thank you for your consideration of this request.
 

Consumer’s name:

Consumer’s contact information:

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