Cardholder Dispute Form

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

Card Information

Account/Member Number

Cardholder Name *

Card Number *

Phone Number *

At the time of the transaction(s): *

This card was still in my possession

This card was lost

This card was stolen

I never received this card

Date Lost/Stolen

Transaction Information

Transaction Date *

Merchant Name *

Dollar Amount *

Additional Transactions

(if you have no additional transactions, skip to the next page)

Transaction Date

Merchant Name

Dollar Amount

Transaction Date

Merchant Name

Dollar Amount

Transaction Date

Merchant Name

Dollar Amount

If you have more than four fraudulent charges on your card, please contact the credit union at (260) 432-3433.

Reason for Dispute

Did you make this purchase? *

Yes

Yes, but I was charged an incorrect dollar amount

No

If yes, what were you trying to purchase (product, cost, merchant name)?

Have you ever used this ATM or merchant before? *

Yes

No

Was this from a free trial/sample that you were later charged for? *

Yes

No

Did you let someone else use your card? *

Yes

No

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.

Please write a summary of what action the company advised you to take. *

Any other information?

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

Thank You!

We will contact you if we need any more information.