What is the chargeback evidence worksheet form template?
When a customer disputes a card payment, the merchant usually has a fixed window to respond through their payment processor. Winning depends on submitting the right evidence for the dispute reason: proof of delivery for an item not received, access logs for a digital product, the refund policy for a cancelled subscription.
This worksheet takes you through it: the dispute, reason and deadline and whether you'll challenge or accept it, the order and checkout checks, delivery or service evidence based on how the order was fulfilled, customer communication and refunds, and finally the documents, evidence files and a short response summary.
It doesn't submit anything to your processor. It's your internal record of the case, saved as a PDF in FileIt with the evidence attached, ready to copy into the processor's dispute portal and to refer back to later.
- Best for
- Online stores, subscription businesses, hotels, travel and service businesses that take card payments
- Filled in by
- The merchant, finance or customer service team handling the dispute
- Time to complete
- 15 to 20 minutes with the order history to hand
- Includes
- Reason-based follow-ups, checkout checks, delivery evidence by fulfilment type, refund details and up to 10 evidence files
Who uses a chargeback evidence worksheet form?
- An online store responding to an item-not-received chargeback
- A software company defending a cancelled-subscription dispute
- A hotel answering a dispute over a no-show charge
- A finance team logging every dispute and its outcome
- A small business owner learning what evidence processors expect
- A customer service team handing a case over to finance
Questions on this chargeback evidence worksheet form
36 questions over 5 pages · includes file upload, conditional questions, multiple pages.
1 The dispute
- Business or merchant account name*
- Dispute or case number*
- Payment processor or acquirer* Stripe · PayPal · Square · Adyen · Shopify Payments · Bank merchant account · Other
- Card network* Visa · Mastercard · American Express · Discover · Other
- Date the dispute was received*
- Response deadline*
- Disputed amount*
- Dispute reason given* Fraudulent or unauthorised transaction · Product or service not received · Not as described or defective · Subscription or recurring charge cancelled · Refund or credit not processed · Duplicate charge · Other
- Reason code, if shown
- What are you going to do?* Challenge it with evidence · Accept the chargeback
- Why are you accepting it?* asked only when it applies
2 The order
- Order or invoice number*
- Order date*
- Customer name*
- Customer email
- What was bought*
- Card last 4 digits
- Checks passed at checkout Address verification (AVS) matched · CVV / security code matched · 3-D Secure authentication · Billing and shipping address match · Customer has paid before without dispute · Customer was logged in to their account
3 Delivery and service
- How was it delivered?* Shipped · Collected in person · Digital product or download · Service provided
- Carrier and tracking number* asked only when it applies
- Delivery date* asked only when it applies
- Signature or photo proof of delivery available? asked only when it applies
- Evidence of access or download* asked only when it applies
- Evidence the service was provided* asked only when it applies
- Evidence of collection* asked only when it applies
4 Communication and policy
- Did the customer contact you before disputing?*
- Summary of communication with the customer* asked only when it applies
- Has any refund or credit already been given?*
- Refund amount* asked only when it applies
- Refund date* asked only when it applies
- Were your refund or cancellation terms shown to the customer at checkout?*
5 Evidence and response
- Documents attached* asked only when it applies Receipt or invoice · Order confirmation email · Proof of delivery · Customer emails or chat logs · Terms and refund policy · Screenshots of product or listing · Usage or login records · Signed contract or agreement
- Evidence files* asked only when it applies
- Response summary for the processor* asked only when it applies
- Prepared by*
- Date submitted to the processor
The chargeback evidence worksheet form, page by page
1 The dispute
Record the merchant account, case number, payment processor, card network, the date the dispute arrived, the response deadline and the disputed amount. Choose the dispute reason and add the reason code if shown. Decide whether to challenge it or accept it; accepting asks why.
2 The order
Enter the order number and date, customer name and email, what was bought and the card's last four digits. Tick the checks passed at checkout, such as address verification, CVV, 3-D Secure, matching addresses or a logged-in customer.
3 Delivery and service
Choose how the order was delivered. Shipped orders ask for the carrier and tracking number, delivery date and whether signature or photo proof is available; digital products, services and collections each ask for their own evidence.
4 Communication and policy
Say whether the customer contacted you before disputing, with a summary if so, and whether any refund or credit was already given, with the amount and date. Confirm whether your refund or cancellation terms were shown at checkout.
5 Evidence and response
If you're challenging the dispute, tick the documents you're attaching, upload up to ten evidence files and write a short, factual response summary for the processor. Finish with who prepared the case and the date it was submitted.
Make the template yours
- Edit the processor list to the ones you use
- Change the currency on the amount fields
- Add your own reason codes as a dropdown if you see the same ones often
- Add an outcome question (won, lost, pending) to update when the processor decides
- Email the finance team every time a new dispute is logged
- File cases into a vault folder per month or per processor
Tips for a better chargeback evidence worksheet form
- Note the response deadline first; a late response usually means losing the dispute
- Match your evidence to the dispute reason rather than sending everything you have
- Keep the response summary short, factual and polite
- Remove full card numbers or unnecessary personal data from screenshots before uploading
- Look for patterns across disputes to fix the cause, such as unclear billing descriptors
Every response becomes a PDF in your vault
Each worksheet is saved as a PDF in your FileIt vault with its evidence files, and your team can be emailed when a new case is logged.
The Responses table gives you a dispute log you can filter by reason or processor and export to CSV to track volumes and outcomes.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Chargeback evidence worksheet form: frequently asked questions
Is this chargeback evidence worksheet free?
Yes. It's included in the FileIt Forms app on every account, including the free plan.
Does it submit my response to the processor?
No. It organises your case and evidence. You submit the response through your payment processor's own dispute process.
Will using it help me win disputes?
It helps you gather the evidence processors commonly ask for, but every dispute is decided by the card issuer and network rules, so no form can guarantee an outcome.
Can I record the full card number?
No. The form only asks for the last four digits, which is all you need to identify the card.
What evidence does each delivery type ask for?
Shipped orders ask for tracking and delivery date, digital products for access or download records, services for proof the service was provided, and collections for evidence of collection.
Can I log disputes I decide to accept?
Yes. Choose accept and record why, so you still have a full record of every dispute. The evidence upload and response summary are skipped for accepted disputes.