Visa Debit Card Dispute Form
7905 Malcolm RD, STE 311 Clinton, MD 20735
TEL: 800‐877‐7328 x.8810
FAX: 301‐856‐4409
The VISA Debit Card Dispute Form should be completed when a known person or merchant has debited a VISA Debit Card under
the following circumstances:
Cancella on Dispute
Transac on was Paid by Other Means
Returned Merchandise/Credit Not Received
Non‐Receipt of Goods or Services
Duplicate Charge
Incorrect Transac on Amount
This form must be signed and filled out completely.
All cardholder documenta on (such as receipts, correspondence with the merchant, etc.) should be submi ed with this form.
Please include your day me contact number and email address.
USPS FCU cannot cancel a charge or place a stop payment on debit card transac ons.
Return this form to any USPS FCU branch loca on, or mail it to USPS FCU VISA Dept. 7905 Malcolm RD, STE 311 Clinton, MD
20735, or fax the form to USPS FCU VISA Dept. at 301‐856‐4409.
Cardholder Name: _____________________________________ Card Number: _________________________________________
Day me Contact Number: _______________________________ Email: _______________________________________________
Transac on Date: ______________________ Merchant Name: ______________________________________________________
Transac on Amount: ___________________ Disputed Amount: ________________________
This is transac on ______ of ______ transac ons that I am dispu ng.
(Example: This is transac on 1 of 3 transac ons that I am dispu ng.)
__________________________________________________________________ ________________________________________
Cardholder Signature
Date
Your signature above is required. Please ch
below that
Please answer all appropriate ques ons below. Required fields are marked with an asterisk (*). A ach a separate sheet or le er if
more room is needed for your explana on. If any of the below does not accurately reflect your dispute please contact the USPS
FCU VISA Department at 800‐877‐7328 x.8810.
___ Cancella on Dispute
* Date of Cancella on: ____________________ Spoke with: _________________________________________________
* Reason for Cancella on: _____________________________________________________________________________
___ I Cancelled this Recurring Transac on with the Merchant
Date Cancelled: __________________ how
: ____________________________________________
(telephone, in‐person, etc.)
* Describe your a empt to resolve this dispute with the merchant:
___________________________________________________________________________________________________
Card Number: __________________________________________
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