Unauthorized Card Transaction Dispute

UNAUTHORIZED CARD TRANSACTION DISPUTE

First Name *

Last Name *

Card Number *

Transaction Information

Please complete a separate form for each disputed transaction.

Merchant Name *

Transaction Date *

Transaction Location: City *

Transaction Location: State *

Transaction Date

Amount $ *

Affidavit: I submit this dispute to report the unauthorized and fraudulent use of my credit or debit card. I did not give, sell or trade my credit or debit card to anyone nor give anyone permission to use my credit or debit card. I did not receive any benefit from the unauthorized use of my credit or debit card. I have never shared my credit or debit card or PIN with anyone and have never authorized anyone to use my credit or debit card.

Please include the status of your card at the time of the transaction:

My card was lost

Date Lost

My card was stolen

Date Stolen

My card is still in my possession

Please note, this form will alert the Credit Union that you are disputing a transaction processed with your credit or debit card. If you are disputing multiple transactions, you must complete one dispute form for each disputed transaction. The Credit Union will research the transaction on your behalf and submit the dispute to our card processor for processing. In some instances, we may require a live signature and additional forms to complete the dispute process. We will deliver these additional forms to the email address you provide below.

Email Address

Please upload an image to securely submit the documentation for this dispute. Acceptable formats are .png,.jpg,.jpeg. The maximum size of the uploaded file is 3 megabytes (3mb).

Click or drag & drop image here to upload

OR

Please upload a file to securely submit the documentation for this dispute. Acceptable formats are .pdf,.docx,.doc,.odt,.rtf,.txt. The maximum size of the uploaded file is 3 megabytes (3mb)

Click or drag & drop file here to upload

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