Notification of Fraudulent Transaction

* Indicates Required

• Cardholder Information

  Cardholder Name*

  Email*

  Phone *

  Debit Card Number*

• Dispute Reason/Elaboration

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

  Card Lost

  Date card was Lost*

  Card Stolen

  Date card was Stolen*

  Card is still in Accountholder's Possession

  Is counterfeit card use suspected?*

  Yes No Whether counterfeit card use is suspected is required

  New or Reissue Card Never Received

  I, the Cardholder, deny authorizing or participating in the disputed transaction. To the best of my knowledge, no one authorized to use this account signed for or participated in the transaction(s):*

  Yes No

  Selection is required

  Status of Card is required

• Transaction Information

  Transaction Date*

  Date 1

  Merchant Name*

  Merchant 1

  Dollar Amount*

  Amount 1

  Multiple Transactions

  Date 2

  Merchant 2

  Amount 2

  Date 3

  Merchant 3

  Amount 3

  Date 4

  Merchant 4

  Amount 4

  Date 5

  Merchant 5

  Amount 5

  Date 6

  Merchant 6

  Amount 6

  Date 7

  Merchant 7

  Amount 7

  Date 8

  Merchant 8

  Amount 8

  Date 9

  Merchant 9

  Amount 9

  Date 10

  Merchant 10

  Amount 10

  Date 11

  Merchant 11

  Amount 11

  Date 12

  Merchant 12

  Amount 12

  Date 13

  Merchant 13

  Amount 13

  Date 14

  Merchant 14

  Amount 14

  Date 15

  Merchant 15

  Amount 15

  Date 16

  Merchant 16

  Amount 16

  Date 17

  Merchant 17

  Amount 17

  Date 18

  Merchant 18

  Amount 18

  Date 19

  Merchant 19

  Amount 19

  Date 20

  Merchant 20

  Amount 20

• Statement

  I, submit this notice for the purpose of establishing the fraudulent use of my card. I did not give, sell or trade my ATM/Debit Card to anyone nor give anyone permission to use my card(s). I have no knowledge that my spouse or minor children made any transaction(s) on or after that date of the first fraudulent transaction indicated below. I did not receive any benefit from the unauthorized use of my ATM/Debit Card.

  I give my consent to the credit union to release any information regarding my card/and or card account to any local, state and/or federal law enforcement agency so that the information can, if necessary, be used in the investigation and/or persecution of any person(s) who may be responsible for fraud involving my card and/or card account. Further, I understand I may be required to comply with a court order or subpoena to give testimony. I swear this statement is true and understand that making a false sworn statement is subject to federal and/or state statues and may be punishable by fines and/or by imprisonment.

  NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, submits a statement of claim containing any false, incomplete or misleading information commits a crime.

  
  

  Written Statement:*

  Cardholder Name (type name)*

  Date*

  Cardholder Signature*

  Clear Signature