Cardholder Dispute Form - Affidavit Of Fraudulent Account Activity
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1
2Claim No.____________________
Sate & Contract No. AL, 00104087
CARDHOLDER DISPUTE
AFFIDAVIT OF FRAUDULENT ACCOUNT ACTIVITY
Debit Card
Credit Card
ATM
Date:
Employee:
I make this Cardholder Dispute Form for the purpose of establishing the fraudulent use of my card. I did not give, sell or
trade my credit/debit card to anyone nor did I 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 the date of the first fraudulent transaction indicated below.
I did not receive any benefit from the unauthorized use of my Credit/Debit/ATM card.
1.
My name is
My permanent address is
Street
City
State
Zip Code
2.
Home telephone number
Work telephone
Work telephone
3.
Army Aviation Account Number
. I am the
Main Member
Joint Member
Other
4.
Type of Card Loss:
Lost
Stolen
Never Received
Cards in my Possession
5.
Number of Cards Issued to this account ____. The Number on the Card _________________ ATM card issue #___
6.
Date Cardholder Discovered the Loss:
7.
Date Cardholder Reported Loss to Credit Union/Processor:
8.
Date of the First Fraudulent Transaction:
9.
EMAIL ADDRESS REQUIRED:
I did not use this card nor authorize the use of this card by anyone else after I discovered the plastic card was lost,
stolen of counterfeited.
Total amount of unauthorized transactions: $___________________
I have examined all of the unauthorized transactions and in each instance I did not originate the transaction nor
authorize it. Further, I did not receive any of the proceeds or benefits of any such items(s) on the above total.
Name and Address of Unauthorized User (if known)
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 account. I swear this Cardholder
Dispute Form is true and understand that making a false sworn statement is subject to federal and/or state statutes and
may be punishable by fines and/or imprisonment.
YES
NO The above card was requested by me.
STATE OF
COUNTY OF
Subscribed and sworn to before me this
______ day of _________________, 20____
Member
Date
(Notary Public)
Co-Applicant/Authorized Signature
Date
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