Authorized Card Transaction Dispute

AUTHORIZED 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 $ *

I certify that the transaction was authorized, however I’m disputing the transaction because ONE of the following:

The merchant charged my card twice on the same day for the same item.

The charge was paid by another means.

I cancelled this transaction with the merchant.

I ordered merchandise from the merchant, however the merchandise never arrived.

I cancelled a reservation.

I cancelled this recurring charge with the merchant. However, merchant continues to bill me after my cancellation.

I received merchandise/services different from what I requested/authorized.

Please note: It is the member’s responsibility to contact the merchant and attempt to resolve your dispute. If you are unsatisfied with the results of your attempt/s to resolve the issue, we may dispute the charge on your behalf. You must provide the Credit Union with a detailed letter explaining what attempts were made to resolve this issue and any supporting documentation you have to support your dispute.

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

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

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

Phone Number *

Submit