Debit Card Fraud Form

Card Holder Name*

First NameLast Name

Account Number*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home/Cell Phone Number*

Please enter a valid phone number.

Work/Cell Phone Number

Please enter a valid phone number.

Card Number*

ATM Location

Street Address

Street Address Line 2

CityState

Postal / Zip Code

Amount Requested

In U.S Dollars

Amount Received

In U.S Dollars

Amount Difference

In U.S Dollars

Do you have a receipt for the transaction in question?

YesNo

Date*

Date

Amount*

In U.S Dollars

Merchant Name:*

Date

Amount

In U.S Dollars

Merchant Name:

Date

Amount

In U.S Dollars

Merchant Name:

Date

Amount

In U.S Dollars

Merchant Name:

For more transactions, please list them here in the same order: Date, Amount, and Merchant Name.

Do you have a receipt for the transaction(s) in question?*

YesNo

Are you in possession of your Check Card(s)?*

YesNo

If not, what date was it missing/lost/stolen?

Date

Where do you believe it was missing/lost/stolen?

Member's Initials

Initial Here

When did you first report this to the Credit Union?*

Date

Have you ever authorized anyone to use your Check Card(s)*

YesNo

Is there another account owner who may have made this withdrawal?*

YesNo

If yes, who?

Where are your card(s) kept?*

Where is your PIN code kept?*

Is the PIN code written on the card?*

YesNo

Have you contacted the merchant in an attempt to resolve this error?*

YesNoN/A

If yes, which Merchant?

Date Contacted

Date

What did the merchant say?

Is the transaction believed to be fraudulent?*

YesNo

How the transaction was canceled:

Date of cancellation

Date

Reason

For service canceled by fax, letter, or email, a copy of the sent email, letter, or fax confirmation must be provided. Please choose a file to upload.

pdf, doc, docx, jpg, jpeg, png

A detailed explanation is required as to why this claim is being disputed: Please provide the dates, names, steps taken to receive credit back from the merchant, and any paperwork received from the merchant.*

Provisional credit is a loan from the credit union given to those in the dispute so that they may continue on without disruption of their daily tasks. Provisional credit is given within 5 days for Visa transactions or 10 days for ATM transactions if the dispute cannot be resolved within the time frame. It can take up to 45 days for Visa transactions or 90 days for ATM transactions to investigate (See regulation E 205.11 & Visa Rules.) Results of the investigation will be provided to the member. If it is found that the transaction in dispute is not unauthorized or will not be refunded, the provisional credit will be reversed from the account and a letter will be sent to notify the member. Member must be willing to prosecute if the criminal is found. The transaction(s) described were not originated with fraudulent intent by me or any person acting for or with me.

I neither conducted, authorized nor benefited from these transactions. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge.

Cardholder Signature:*

Date*

Date

Debit Card Fraud Form

Section 1

Section 2

Section 3

For Canceled Service