Fillable Visa Check Card Purchase Dispute Disputed Electronic Funds Transfer Notification Form printable pdf download

Visa Check Card Purchase Dispute

Disputed Electronic Funds Transfer Notification

Please mail to: FAA Credit Union, P.O. Box 26406, Oklahoma City, OK 73126

Cardholder Name:_______________________________ Card Number: _________________________

Address:____________________________________ City, State Zip:____________________________

Daytime Phone:__________________ Email:_______________________

Merchant Name:_______________________ Transaction Date:___________ Amount: $___________

Cardholder Statement of Disputed Item

I have examined the charge(s) made to my account and wish to dispute the purchase for the following reason. I am enclosing

a copy of all related documents, including any receipts, invoices and details of my attempts to resolve this matter with the

merchant. (Visa requires that a good faith effort attempt to resolve with merchant be made prior to disputing a transaction).

☐ Fraudulent transaction. I have NEVER done business with this merchant and have not received any benefits or services

from this transaction. Attempted to resolve with merchant (date): _____. Please describe below.

☐ I do not recognize or remember this transaction.

☐ Merchandise or services not received. Date expected:_____ Date attempted to resolve with merchant:______. Please

describe below.

☐ Transaction paid for by other means. Include proof of payment by other means.

☐ Cancelled services. Date cancelled:______, cancellation number (if any):______.

☐ Duplicate or multiple charges.

☐ Returned merchandise. (Must allow 30 days from date of return). RMA number from merchant:______.

Date returned:_____. Shipping company used:____ Include copy of shipping receipt.

☐ Other – Please describe below.

Error description:_____________________________________________________________________

Cardholder Signature: x_____________________________________________ Date:_______________

If you claim that the ATM transaction was unauthorized, please answer the following questions and sign the Electronic Funds

Transfer Affidavit.

1. When did you discover your card missing? Date:____ Time:____ ☐AM ☐PM

Was it: ☐Lost ☐Stolen

2. Was your Personal Identification Number (PIN) written anywhere? ☐Yes ☐No

3. Was your PIN with the card? ☐Yes ☐No

4. Have you ever allowed anyone to use your card? ☐Yes ☐No

5. Where was the last ATM you used with your card? ______________________________________________

6. Did you notify the police of the unauthorized use? ☐Yes ☐No

Electronic Funds Transfer Affidavit

I make this Affidavit voluntarily for the purpose of establishing the fraudulent use of my plastic card by an unauthorized person(s). I

swear this Affidavit is true and understand the ALL VIDEO TAPES OF THE TRANSACTION WILL BE TURNED OVER TO POLICE FOR

IDEFITICATION OF THE PERPETRATOR. Willful violations of the Federal Electronic Transfer Act Regulation E carry criminal

penalties and conviction for fraudulent use of EFT services carries a $10,000.00 fine and a 10-year jail term.

I (we),______________________________________ certify on this date ________________ that I (we) have read the Electronic Funds

Transfer Affidavit and have no knowledge of and did not make or authorize the transaction(s) attached to this document.

Cardholder Signature: x________________________________________________________

Visa Check Card Purchase Dispute Disputed Electronic Funds Transfer Notification Form