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Card Holder Disputed Item Form

Member Information

Card Information

  • Card type *
  • Reason for dispute *

Unauthorized Transactions

Merchant Name Date Amount
  • Is the Unauthorized User known? *
  • Has this been reported to the police department? (A police report may be required to process dispute request.) *
  • The following explains my dispute *
    Describe your attempts to resolve the matter with the merchant as well as the expected date of delivery on the additional space provided.
    Merchant cancellation policies may apply; please provide full details on the additional space provided.
    Merchant cancellation policies may apply; please provide full details on the additional space provided.
    Please provide full details on the additional space provided.
    Describe in the additional space the defect or damage and attempts to return the merchandise, and the merchant's response
    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.
    Provide a reason for request in additional space provided.
    Your card will be blocked.
    Provide a reason in additional space provided.

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? *
  • Contact method *

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