Client Intake Form
Palisade Dispute Resolution
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Country of Residence
*
Please Select
Canada
US
Transaction & Dispute Details
Merchant Name/Website
*
Date of Transaction
*
-
Month
-
Day
Year
Date
Transaction Amount
*
Payment Method
*
Please Select
Debit Card
Credit Card
Bank Transfer
Other
Bank or Card Issuer
*
Please Select
Visa
Mastercard
AMEX
Discovery
Other
Have You Attempted a Refund with The Merchant
*
Yes
No
Reason for the Chargeback
What is the Reason for the Chargeback?
*
Unauthorized Charge
Merchant Did Not Deliver Service/Product
Misrepresentation (False Advertising)
Unauthorized Subscription
Refund Denied by Merchant
Briefly Explain Your Dispute
*
Supporting Evidence
Upload Screenshots/Photos of Transaction Receipts
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Screenshots of Chats/Emails with Merchant
Browse Files
Drag and drop files here
Choose a file
(Optional, but recommended)
Cancel
of
Upload Screenshot of Merchant’s Refund Policy (If Available)
Browse Files
Drag and drop files here
Choose a file
(Optional, Helps Strengthen Case)
Cancel
of
Agreement & Submission
I confirm that all information provided is accurate and truthful.
*
I confirm
I understand that my case will be reviewed before approval, and if approved, I will receive an invoice for the upfront fee.
*
I understand
I understand that success fees are only charged after a full refund is confirmed.
*
I understand
Submit Case for Review
Should be Empty: