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Fillable Check out ingdirect.com for more information. Full Name: Customer ...

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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...
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