Debit Card Dispute Form

* Indicates Required

• Cardholder Information

  Name or Organization Name*

  Date*

  Address*

  Address Line 2

  City*

  State*

  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

  Zip*

  Home Phone*

  Work Phone

  Card Information

  Card Type*

  Debit Card ATM Card

  Card Type is required

  Last 4 Digits of Card Number*

  Account Number*

  Is This Card Closed?*

  Yes* No

  *Required for Unauthorized Use

  Whether the card is closed is required

  Date Closed*

• Unauthorized Use

  I, the undersigned claimant declare, as appropriate that:

  I did not use, nor authorize anyone else to use, the ATM or Debit Card issued to me by Millstream Area CU when said card was used to withdraw funds from my account at the Bank; or

  I did not receive any value or benefit from proceeds of the card transaction(s) and no proceeds were applied to any use or purpose on my behalf; or

  I have not arranged with the person(s) who misused the card to be reimbursed for proceeds of the card.

  Furthermore, I have made available all knowledge, ideas, or suspicions, if any, or the identity of the person who wrongfully used my card and will make available any such knowledge gained in the future and agree to assist and cooperate fully, without limitation, with any investigation pertaining to this matter, whether by federal, state, local, or bank investigators, including testifying before a grand jury or in a court of law against the party responsible for the improper or unauthorized use of the ATM or Debit Card. I hereby certify by signing below that the above information is true and correct.

  Claimant's Signature* (type name)

  Name of Organization (if applicable)

  A FALSE DECLARATION TO A FEDERALLY INSURED FINANCIAL INSTITUTION MAY BE A VIOLATION OF FEDERAL AND/OR STATE LAW.

• Dispute Information

  Did you originally participate in the transaction(s) or lost/stolen?

  You did not originally participate You did originally participate

  Whether or not you participated in the transactions is required

  Claim Circumstances

  Customer Did Not Participate in Transaction(s) or Lost/Stolen

  Please give a brief description of the circumstances of claim and conversation between merchant and cardholder.*

  Is card still in your possession?*

  Yes No

  Whether or not the card is still in your possession is required

  When was the card discovered missing?*

  Have you ever allowed anyone to use the card?*

  Yes No

  Whether or not you allowed anyone to use the card is required

  Who?*

  Was the PIN/Secret Code number with the card?*

  Yes No

  Whether the PIN was with the card is required

  Who, besides you, had knowledge of the PIN/Secret Code number?*

  Was a police report filed?*

  Yes No

  Whether a police report was filed is required

  Case #

  Police Department

  Officer Contact Name

  Dispute with Merchant - Customer Originally Participated in Transaction(s)

  Any requested documentation is required for Visa to process your claim (i.e. receipts, proof of return, etc.)

  Have you attempted to resolve your dispute with the merchant?*

  Yes No

  Resolve with merchant is required

  You must attempt to reach a resolution with the merchant before proceeding.

  Specific date of last contact

  How did you contact the merchant?

  In person By phone By email By mail Using a chat service Other

  Method of contact with merchant is required

  Specify

  Who did you speak to?

  What was said?

  Please check the ONE category that best describes your dispute.

  I have no knowledge of the ATM withdrawal(s) listed below.

  The purchase was paid by check, cash, or other means but was still charged to my card

  Attach a copy of (a) the cash receipt, or (b) the front and back of canceled check, or (c) the copy of the other receipt.

  The amount I authorized differs from the amount that appears on my statement.

  Attach a copy of sales slip or invoice.

  I have received a credit slip from the merchant, however, credit has not appeared on my statement.

  Attach a copy of the credit slip.

  I did authorize the purchase, however:

  I have not received the merchandise.

  Expected receipt date:

  I have not received expected services.

  Attach a letter of explanation

  The merchandise received was returned.

  Return date:

  Attach proof of return

  I attempted to cancel a purchase.

  Date of Attempt

  Attach copies of correspondence with merchant.

  The above item was billed monthly and I cancelled my service.

  Cancellation date:

  Attach corredpondence

  The purchase was a canceled hotel reservation.

  My cancellation number is:

  Category of dispute is required

  Please attach supporting documents

  Accepted formats: .pages, .doc, .docx, .pdf, .png, .jpg

  Select files from your computer
  or simply drag & drop them here

  ---

• Merchants and Amounts

  Date

  Merchant

  Amount ($)

  Date 1

  Merchant 1

  Amount 1

  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

  Date 21

  Merchant 21

  Amount 21

  Date 22

  Merchant 22

  Amount 22

  Date 23

  Merchant 23

  Amount 23

  Date 24

  Merchant 24

  Amount 24

  Totals:

  You should expect resolution or provisional credit in accordance with the provisions and disclosures set forth in your card agreement.