Direct Dispute Form
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1Direct Dispute Form
Customer Indentifying Information
Name
_____________________________
SSN
____________________
Address
_____________________________
Phone ____________________
_____________________________
____________________
Dispute Information
Account Number
___________________
Information being disputed __________________________________________________
__________________________________________________
Basis/Reason for Dispute
__________________________________________________
__________________________________________________
Supporting Documentation (please attach)
Account Statements
Police Report
Fraud/Identity Theft Affidavit
Court Order
Consumer Report (credit report, Chex Systems report, etc)
Other: _________________________________________
Customer Signature _____________________________
Date
______________
For Bank Use Only
Date Received _______________
Received by
__________________________
Investigation Information
Date Started _________
Date Ended ________
Investigated by _____________
Information Reviewed
__________________________________________________
__________________________________________________
Conclusions/Findings
__________________________________________________
__________________________________________________
Resolution
Corrected information sent to __________________________________
Date: Sent to CRA __________
Corrected on system ________
Frivolous/Duplicate dispute
Irrelevant Dispute/Insufficient Info
Info accurate, Credit Reporting Agency error (customer to contact CRA)
Info reported correctly, no corrections made/sent
Written notification of results sent to customer (required for all disputes)
Find this tool and more on Banker Tools on
Rev 05/2010
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Parent category: Financial