Cardholder Dispute Form & Fraudulent Use Affidavit
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3Cardholder Dispute Form & Fraudulent Use Affidavit
ATM/Debit/Credit Cards
Please fax to 202-673-3508 or email to
Today’s Date: ______________
Member Number: _______________________________
Card Number_______________________________________
Last 4 Digits of S.S. #____________________________
Cardholder’s Name: _________________________________
Total Amount of Loss ($):_________________________
Email Address: __________________________________
Home Phone: __________________________________
Work Phone: ___________________________________
Cell Phone:_____________________________________
Mailing Address___________________________________________________________________________________
Street
City
State
Zip
Physical Address (if different) _________________________________________________________________________
Street
City
State
Zip
I requested the card:
Yes
No
Number of cards issued with this number__________________________
Type of Card:
Credit Card
Debit Card
ATM Card
At time of disputed/fraudulent transaction, my card was:
Lost
Stolen
In my possession
Not received
Date loss was discovered: ____________________
Date loss reported to Credit Union/Processor:_______________
Have you ever granted permission for anyone (other than yourself) to use your card?
Yes
No
If yes, who:_____________________________________________________________
Have you previously transacted business with this/these merchants?
Yes
No
If yes, did you contact the/these merchants:
Yes
No
Date/Amount/Merchant Name for your last authorized transaction:__________________________________________
Date/Amount/Merchant-Location of the first fraudulent transactions:_________________________________________
Was Law Enforcement notified?
Yes
No
If yes, Agency & Phone:_________________________________________________ Case No. ______________________
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