Debit Card Dispute Form

Debit Card Dispute

Cardholder First and Last Name

Last 4 digits of card number

Date Charge/s Discovered

At the time of the transaction(s), please indicate the status of your card

Card Lost

Card still in your possession

Card Stolen

New or Reissue Card, Never Received

If you checked "lost or stolen", enter the date the card was lost or stolen:

Attempt to Resolve: What was the date your contacted the merchant?

Method of Merchant Contact

In-person

Letter

Phone

What is the person's name, email address, phone number, etc.

Explanation of charges, the service or merchandise expected, and attempts to resolve. Provide as many details as possible, may increase your chances of a successful dispute resolution.

#1 Transaction Information - Give Date, Amount, Merchant

#2 Transaction Information - Give Date, Amount, Merchant

#3 Transaction Information - Give Date, Amount, Merchant

#4 Transaction Information - Give Date, Amount, Merchant

#5 Transaction Information - Give Date, Amount, Merchant

#6 Transaction Information - Give Date, Amount, Merchant

Select Issue:

I did not authorize this charge - I have no relationship with this merchant. I certify that I did not authorize or participate in this transaction with the above mentioned merchant, nor did I authorize anyone else to use my card.

I did not receive the merchandise.

I paid by other means. You must provide proof such a copy of the cancelled check, front and back, a cash receipt or a billing statement from another card.

I was billed twice for a single purchase. You certify one transaction is valid, but posted more than once.

I was overcharged for the purchase. You must provide a copy of the signed sales receipt.

Membership cancellation - you must provide a copy of the correspondence informing the merchant of the cancellation

Merchandise was returned. You must provide signed proof of return or return credit slip.

My credit/refund posted as a sale.

By submitting this application to the Credit Union, I/we promise that everything is correct. I declare under penalty of perjury that the forgoing is true and correct to the best of my ability. I state that I have carefully examined my checking and/or savings statement(s) and find that the above-described transaction(s) were not processed as requested by me, nor did I receive benefit or proceeds from the transactions. I swear this affidavit is true and understand that ALL VIDEO TAPES OF THE TRANSACTIONS WILL BE TURNED OVER TO POLICE, AND willful violations of the Federal Electronic Funds 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 declare under penalty of perjury that the forgoing is true and correct to the best of my ability.

Debit Card Dispute Form

Latest News -