Fillable Fraudulent Transaction Dispute Form printable pdf download

Card#______________________________ Page ______of__________

FRAUDULENT TRANSACTION DISPUTE FORM

Name: ____________________________________________________ Visa card number: _______________________________

I certify that my Visa card was: (select one)

Lost (0)

Stolen (1)

Card not received (2)

Counterfeit (4)

Card is still in my possession (6)

The following transactions were not made by me or anyone authorized to use my Visa card:

1. Date: _______________ Amount: _____________________ Merchant: _________________________________________

2. Date: _______________ Amount: _____________________ Merchant: _________________________________________

3. Date: _______________ Amount: _____________________ Merchant: _________________________________________

4. Date: _______________ Amount: _____________________ Merchant: _________________________________________

5. Date: _______________ Amount: _____________________ Merchant: _________________________________________

6. Date: _______________ Amount: _____________________ Merchant: _________________________________________

7. Date: _______________ Amount: _____________________ Merchant: _________________________________________

8. Date: _______________ Amount: _____________________ Merchant: _________________________________________

9. Date: _______________ Amount: _____________________ Merchant: _________________________________________

10. Date: _______________ Amount: _____________________ Merchant: _________________________________________



I complete the Cardholder Dispute form for the purpose of establishing the fraudulent use of my Credit/Debit/ATM card(s).



I did not give, sell, or trade my card(s) to anyone nor did I give anyone permission to use my card(s).



I have no knowledge that my spouse or minor child(ren) made any transaction(s) on or after the date of the first fraudulent transaction(s).



I did not receive any benefit from the unauthorized use of my Credit/Debit/ATM card(s).



I did not use my card nor authorize the use of my card by anyone else after I discovered the unauthorized use of my card.



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 proceeds or benefits from any of these transactions.



I give my consent to have this dispute/claim reviewed by a credit union investigator and understand that I may be asked to provide additional

details for this investigation.



I understand that incomplete or inaccurate information could result in the decline of my dispute.

_______I understand I will be charged $25 per transaction that is shown to be a charge I authorized.

(Please Initial)

I give my consent to University Federal 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 account. Include a copy of the Police Report if total dollar amount exceeds $500.

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.

____________________________________________________ ____________________________________

Cardholder signature

Date

Institution use only:

Submitted by:

Fraudulent Transaction Dispute Form

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