Debit Card Transaction Fraud/dispute Form (Page 2 of 3) in pdf

Part IV Dispute Transactions

I did authorize the transaction(s) - I certify that I did authorize or participate in the transaction(s) with the merchant. However; this

transaction(s) includes an error selected from the options below. I have made an effort to resolve the situation with the merchant

and the merchant has not corrected the error. If applicable I did return disputed merchandise using a traceable shipping method

(UPS, Federal Express, DHL, US Postal Service).

Date Merchant was Contacted _____ /_____ /_____ Name of Representative _____________________________

Use this section to provide a detailed explanation of your dispute and the outcome of the contact, if necessary.

Select One Dispute Reason Below:

1. The ATM transaction listed is incorrect. Amount Requested $ __________ Amount Received $ __________

0.00

2. I was charged the wrong amount. My receipt shows $ ____________. (Please attach a copy of your sales receipt.)

0.00

3. My account was charged twice for the same transaction. I authorized only one charge with the merchant for

$ ____________. (Please attach a copy of your sales receipt.)

0.00

4. I was issued a credit which did not post to my account. (Please attach a copy of your credit slip.)

5. I used another form of payment (cash, check, credit/debit card) for this transaction. (Please attach a copy of

your proof of alternate payment.)

6. I cancelled a subscription/membership/policy (circle one), prior to the transaction date, however it was still

charged to my account. (Please attach a copy of the letter, email, or fax requesting the cancellation and/or

a copy of your contract.)

- Date you contacted the merchant to cancel? _____ /_____ /_____

Cancellation # ____________________

7. I cancelled a reservation, prior to the transaction date, however I was still charged for it.

- Date you contacted the merchant to cancel? _____ /_____ /_____

Cancellation # ____________________

8. I authorized the transaction however I have since returned the merchandise and have not received a credit

from the merchant. (Please attach proof of return, return receipt, or credit slip)

9. I authorized the transaction however I have not received the merchandise.

- What was the expected delivery date? _____ /_____ /_____

10. I authorized the transaction however I am disputing the quality of the service that was provided. (Please attach

supporting documentation, such as contracts, repair bills, or copies of second opinions from a certified

merchant on their invoice or letterhead.)

11. Other - Explain in detail on a separate sheet.

***Attach a separate sheet i you need more space.***

Part V Cardholder Signature Required

The signature of the cardholder must be in this section with the date to prevent a delay in processing.

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 prosecution of any person(s) who

may be responsible for fraud involving my card and/or card account. I agree to fully assist and cooperate with any investigation and/or

prosecution of such persons and swear that the information that I have provided above is true and correct.

Cardholder Signature ___________________________________

Date ____________________

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Debit Card Transaction Fraud/dispute Form Page 2