Disputed Transaction Form

Disputed Transaction Form

For the FLX Prepaid Mastercard
Please ensure you complete all sections in full. Incomplete disputed transaction forms will be returned.

Please refer to the terms and conditions contained in the Product Disclosure Statement in relation to disputed transactions.

Important Note: If your card has been lost or stolen, please ensure you contact FLX.

In the event we are unsuccessful in disputing the transaction and it is found this form has been lodged fraudulently, a disputed transaction fee of $10 will be incurred.
Card Details
Card Number (Last 4 Digits)*
(Last 4 digits of card number only)
Cardholder Name*
(Child's full name as it appears on FLX Card)
Contact Details
Contact Name*
Mobile Number*
Email Address*
Disputed Transaction(s)
Date*

DayMonthYear
Date
Amount ($)*
Transaction details (include merchant name)*
Date*

DayMonthYear
Date
Amount ($)*
Transaction details (include merchant name)*
Date*

DayMonthYear
Date
Amount ($)*
Transaction details (include merchant name)*
Date*

DayMonthYear
Date
Amount ($)*
Transaction details (include merchant name)*
Date*

DayMonthYear
Date
Amount ($)*
Transaction details (include merchant name)*
Please list your transaction/s below:*
Reason for Dispute
Please select the reason that is most appropriate and ensure you attach the corresponding documentation if required.*

I only authorised one transaction and it appears to be duplicated.The transaction I authorised was processed for the incorrect amount.The goods and services I have paid for were damaged, defective, or not as described. I returned the goods or cancelled the services. I have contacted the Merchant to try and resolve this matter.I have not authorised or participated in the transaction(s) listed above.I have not received the goods or services I paid for. I have contacted the Merchant to try and resolve this matter.
Please note that if the above transactions are identified as fraudulent, we may be required to deactivate your card and issue a replacement.
What was the amount that you authorised for this transaction?*
When did you authorise this transaction?*

DayMonthYear
Please describe the damaged/defective or not as described goods or services.*
Please attach:
- Evidence (e.g. photo) of the damaged/defective/or not as described goods or services.
- Proof that the goods and services were returned/services cancelled or an attempt was made.
Relevant Attachments *

You may upload multiple files
Cancelof
What goods or services were purchased?*
When were the goods/services expected to arrive?*

DayMonthYear
When was the last contact made with the Merchant to try to resolve this matter?*

DayMonthYear
Please provide details of the Merchant's Response.*
Unauthorised Transaction Details
Was your child's card lost or stolen prior to the unauthorised transaction?*

YesNo
Date Loss/Theft Occurred *

DayMonthYear
Time Loss/Theft Occurred

Minutes

AM/PM Option
When and how did you become aware of loss/theft?*
How did you report the loss/theft to us?*
e.g. telephone
Date of Reporting to FLX*

DayMonthYear
Time of Reporting to FLX

Minutes

AM/PM Option
How did the loss/theft occur?*
e.g. house break-in
Where did the loss/theft occur?*
e.g. office
If the card was not lost or stolen, where was the card at the time of transaction?
Was the card signed?

YesNo
Did you keep a record of your PIN (either disguised or undiguised)? If so, how was it recorded and where was the record kept?*
Was the record of the PIN stolen as well?*
Has the PIN been disclosed to anyone else (including family members)? If so, provide name, address telephone number and relationship to you.*
Police Report Details

If the card is lost or stolen, a Police report must be submitted to assist the investigation.
Date of reporting loss/theft to Police

DayMonthYear
Time of reporting loss/theft to Plice

Minutes

AM/PM Option
Crime Report Number
Police Officer's Name
Contact Phone Number
Station Name/Location
Additional Information
Please provide any additional information that may help us in assisting with your dispute.
Additional Files

You may upload multiple files
Cancelof
Privacy Notice: EML is collecting your personal information for the purposes of investigating the disputed transaction. Without this information, we will be unable to provide you with the services sought. We may also be required to pass on your personal information to other third party services providers in order to properly investigate your dispute. Subject to some exceptions allowed by law, you may be able to request access to the personal information we hold about you. We will assess your request in accordance with the law, you may be able to request access to the personal information we hold about you. We will assess your request in accordance with the law and tell you why if access is denied. A request to access, update or correct any information should be directed to the Privacy Contact Officer - Level 12, 333 Ann Street, Brisbane City, QLD, 4000.

For further information about how EML handles your personal information please see our Privacy Policy at www.emlpayments.com.
By signing below, you solemnly and sincerely declare and confirm that you neither authorised, participated nor performed the above transaction(s) and you have not given your card to anyone else or colluded with anyone to make this transaction on your behalf. You have no objection to a full investigation being made with the named company and you have no objection to police involvement, should this prove to be necessary.*

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Disputed Transaction Form

Card Details

Contact Details

Disputed Transaction(s)

Reason for Dispute

Unauthorised Transaction Details

Police Report Details

Additional Information