ING Group Fillable Forms
INSTRUCTIONS: Complete all applicable fields. If you need more room, add the information on a separate sheet. Be sure to sign and date the bottom of this form or we'll bounce it back. PERSONAL AND TRANSACTION INFORMATION Full Name: Customer Number: Transaction Date: Merchant Name: Merchant Contact Info: STATEMENT OF DISPUTE Merchandise Not Received: Item purchased: ___ Date ordered: ___/___/___ Expected delivery date: ___/___/___ (Attach proof of expected delivery date; tracking number, invoice, etc Moresign and date the bottom of this form or we'll bounce it back. Return this form and any supporting Less
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