Instructions: 1. All fields must be completed in to process the form. 2. A separate form must be submitted for each agency whose payments resulted in disputed fees. 3. Completed forms should be submitted to . 4. If you have questions, please contact the MFMP Customer Service Desk at 1-866-352-3776 or . Dispute Request Information Date: Federal Tax ID #: Company Name: Contact Name: Title: Phone Number: Contact Email: State Agency: PO, Total Consolidated Disputed Fee Amount Contract Payments Billing Invoice CBI Date Reason for Dispute (value of the or Invoice from the (CBI) # transaction fees) Number state For example: For example: For For For example: For example: 9003492 6/1/2013 example: example: $70 Exempt service, AZ12345 $70,000 construction Total Amount Disputed $ $ For Agency Transaction Fee Dispute Liaison Reviewer Name: Approved: Yes No Date Reviewed: Exemption Reason Code: See listing of reason code descriptions on following page. Comments: Transaction Fee Exemption Codes and Definitions Exemption Code Exemption Reason Notes
Instructions: 1. All fields must be completed in to process the form. 2. A separate form must be submitted for each agency whose payments resulted in disputed fees. 3. Completed forms should be submitted to . 4. If you have questions, please contact the MFMP Customer Service Desk at 1-866-352-3776 or . Dispute Request Information Date: Federal Tax ID #: Company Name: Contact Name: Title: Phone Number: Contact Email: State Agency: Consolidated Billing Invoice (CBI) # CBI Date PO, Contract or Invoice Number Total Payments from the state Disputed Fee Amount (value of the transaction fees) Reason for Dispute For example: 9003492 For example: 6/1/2013 For example: AZ12345 For example: $70,000 For example: $70 For example: Exempt service, construction Total Amount Disputed $ $ For Agency Transaction Fee Dispute Liaison Reviewer Name: Approved: Yes No Date Reviewed: Exemption Reason Code: See listing of reason code descriptions on following page. Comments: Transaction Fee Exemption Codes and Definitions Exemption Code Exemption Reason Notes
MFMP_Dispute_Form_(5)_(9).docx