Notification of Fraudulent Transaction (Debit or Credit Card)

Notification of Fraudulent Transaction

Have you contacted the company debiting your account?

Yes

No

If you have not contacted the company debiting your account, please do so before filling out this document.

If yes, please write a summary of what action the company advised you to take.

Cardholder Name *

Card Number *

Enter Today's Date *

Enter Valid Phone Number *

Dispute Reason/Elaboration

At the time of the transaction(s), please indicate status of card (Please check one):

Card Lost

Enter Date Card was Lost

Card Stolen

Enter Date Card was Stolen

Card still in Accountholder's Possession

New or Reissue Card Never Received

If cardholder still in possession of card, is counterfeit card use suspected?

Yes

No

Issuer certifies Cardholder denies authorizing or participating in the disputed transaction. No one authorized to use this account signed for or participated in the transaction(s).

Transaction Information

Transaction Date *

Merchant Name *

Enter Dollar Amount *

Continue if more than one fraudulent charge occurred.

Transaction Date

Merchant Name

Enter Dollar Amount

Transaction Date

Merchant Name

Enter Dollar Amount

Transaction Date

Merchant Name

Enter Dollar Amount

If You have more than four fraudulent charges on your card, please contact the Credit Union Fraud Department at (260) 432-3433 Ext. 3002

Submit