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Chargeback Receipt

A chargeback receipt documents a reversed transaction initiated through a card network. It is commonly used for dispute tracking, audits, and merchant records.

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CHARGEBACK RECEIPT / DISPUTE RECORD Reversal initiated through card network
Chargeback ID: CBK-2026-0216-0068 Case Status: OPEN / IN REVIEW Date Opened: 2026-02-16 Card Network: Visa
Merchant Summit Office Supply 1880 Mission St, San Francisco, CA 94103 Merchant ID: MID 70219455 · Terminal: TID SF03-11
Cardholder (Masked)
Name
Jordan Parker
Card
Visa •••• 4821
Disputed Transaction
Original Transaction Date
2026-02-10
Original Amount
$86.42 USD
Auth Code
V4K8P2
RRN
004812990771
Order/Invoice
ORD-10492
Chargeback Details
Chargeback Amount
-$86.42
Reason Code
10.4 — Other Fraud / Card-Absent Environment
Dispute Channel
Issuer-initiated
Provisional Credit
Issued (if applicable)
Response Due By
2026-03-03
Notes for Records This document confirms a chargeback case was opened and the transaction is under review. Final outcome may include reversal, representment, or adjustment based on evidence submitted.