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Card Holder Disputed Item Form

Member Information

Member Number *
Name *
Email *
Best Contact Phone *
Address *
City *
State *
Zip Code *

Card Information

Card type *
Credit Card ATM Card Check Card
Card Account Number
Reason for dispute *
Lost Stolen Never Received In my possession at all times when fraud occurred
Date Loss Discovered *
Date of First Fraudulent Transaction *

Unauthorized Transactions

Merchant Name	Date	Amount
Merchant Name #1	Date #1	Amount #1
Merchant Name #2	Date #2	Amount #2
Merchant Name #3	Date #3	Amount #3
Merchant Name #4	Date #4	Amount #4
Merchant Name #5	Date #5	Amount #5
Merchant Name #6	Date #6	Amount #6
Merchant Name #7	Date #7	Amount #7
Merchant Name #8	Date #8	Amount #8
Merchant Name #9	Date #9	Amount #9
Merchant Name #10	Date #10	Amount #10

Is the Unauthorized User known? *
Yes No

Name of Unauthorized User
Address
City
State
Zip Code

Has this been reported to the police department? (A police report may be required to process dispute request.) *
Yes No

Authority contacted
Address
City
State
Zip Code
Phone

The following explains my dispute *
I received a price adjustment (credit slip) on the above transaction and it has not appeared on my statement. I certify that only one transaction was made with the above referenced merchant. On my statement, the same merchant has processed a second charge to my account, which I neither participated in nor authorized. I certify that I participated in the above transaction, but have not received the merchandise.
Describe your attempts to resolve the matter with the merchant as well as the expected date of delivery on the additional space provided.
I certify that I participated in the above transaction, but have returned the merchandise/canceled services per the merchant's instructions and have not received credit.
Merchant cancellation policies may apply; please provide full details on the additional space provided.
I contacted the merchant and canceled the monthly recurring transaction.
Merchant cancellation policies may apply; please provide full details on the additional space provided.
I contacted the merchant and canceled my reservation.
Please provide full details on the additional space provided.
The shipped merchandise I received is defective.
Describe in the additional space the defect or damage and attempts to return the merchandise, and the merchant's response
The merchandise/services were not as described.
If purchase was made over the phone please indicate what was not as described. Otherwise please provide additional details as to what was not as described, ie: color, quantity, etc.
I would like a copy of the sales draft.
Provide a reason for request in additional space provided.
I certify that the charge(s) was (were) not made by me or by a person authorized by me to use my card, nor were the goods or services represented by the above transaction received by myself or by a person authorized by me.
Your card will be blocked.
Other
Provide a reason in additional space provided.
An explanation of your dispute is required
Return/Cancel Date *
Additional Details

In dispute cases except those related to lost/stolen/counterfeit cards, you may be required to make an attempt to resolve the dispute with the merchant prior to filing a dispute.

Have you made an attempt to resolve with the merchant? *
Yes No

Date of contact *
Contact method *
Phone Email
Merchant's response *

Why not?

I, make this affidavit for the purpose of establishing the fraudulent use of my card. I did not give, sell or trade my credit/ATM/check card to anyone nor give anyone permission to use my card(s), I have no knowledge that my spouse or minor children made any transaction(s) on or after that date of the first fraudulent transaction indicated below. I did not receive any benefit from the unauthorized use of my credit/ATM/check card.

I give my consent to the credit union to release any information regarding my card/and or card account to any local, state and/or federal law enforcement agency so that the information can, if necessary, be used in the investigation and/or persecution of any person(s) who may be responsible for fraud involving my card and/or card account. Further, I understand I may be required to comply with a court order or subpoena to give testimony. I swear this affidavit is true and understand that making a false sworn statement is subject to federal and/or state statues and may be punishable by fines and/or by imprisonment.

NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, submits a statement of claim containing any false, incomplete or misleading information commits a crime.

Electronic Signature Agreement
I agree to use an electronic signature on this electronic document. (Read More) *
Name (Signature) *

Savings Information

Checking Information

Vehicle Loan Information

VISA Card Information

Savings Information

Checking Information

Savings Information

Checking Information