Employees Federal Credit Union

Visa® Check Card Purchase Dispute Form &
Disputed Electronic Funds Transfer Notification


Visa® Check Card Purchase Dispute Form

Cardholder Name: Member Number:
Card Number: Cardholder Address:
City, State, Zip: Cardholder Daytime Phone:
Cardholder Email Address: Merchant Name:
Transaction Date: Transaction Amount:
Cardholder Statement of Disputed Item: I have examined the charge(s) made to my account and wish to dispute the purchase for the following reason. I am enclosing a copy of all related documents, including any receipts, invoices and details of my attempts to resolve this matter with the merchant. (VISA requires that a good faith effort attempt to resolve with merchant be made prior to disputing a transaction.)
Fraudulent transaction. I have NEVER done business with this merchant and have not received any benefits or services from this transaction. Attempted to resolve with merchant ____/____/____. Please describe below.
I do not recognize or remember this transaction. Transaction paid for by other means. Include proof of payment by other means.
Merchandise or services not received. Date expected ___/___/___. Date attempted to resolve with merchant ____/____/____. Please describe below.
Defective or wrong merchandise received. Date attempted to resolve with merchant ____/____/____. Please describe details below.
Hotel reservations, car rental, airline tickets, or any other travel related transaction cancelled. Must Include cancellation number/code________________________________. Date cancelled: ____/____/____.
Transaction amount changed after original sale. Include copy of original receipt.
Cancelled services. Date cancelled ___/___/___, cancellation number (if any) ____________________.
Returned merchandise (Must allow 30 days from date of return.) RMA number from merchant _________________________________. Date returned: ____/____/____. Shipping company used: ____________________________ Include copy of shipping receipt.
Duplicate or multiple charges. Other – PLEASE DESCRIBE BELOW:
Error Description:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


Cardholder Signature:_______________________________________ Date:_______/_________/__________




Disputed Electronic Funds Transfer Notification

If you claim that the ATM transaction was unauthorized, please answer the following questions and sign the Electronic Funds Transfer Affidavit.
When did you discover your card missing?
Date:____/____/____ Time:_______________AM   PM
Was your card lost or stolen?
Was your Personal Identification Number (PIN) written anywhere?
Yes No
Was your PIN with the card?
Yes No
Have you ever allowed anyone to use your card?
Yes No
If yes, who and when?
Where was the last ATM you used with your card?
Date:
Did you notify police of the unauthorized use?
Yes     No Police Report #:
Electronic Funds Transfer Affidavit
I make this Affidavit voluntarily for the purpose of establishing the fraudulent use of my plastic card by an unauthorized person (s). I swear this Affidavit is true and understand that, ALL VIDEO TAPES OF THE TRANSACTION WILL BE TURNED OVER TO POLICE FOR IDENTIFICATION OF THE PERPETRATOR. Willful violations of the Federal Electronic Funds Transfer Act Regulation E carry criminal penalties and conviction for fraudulent use of EFT services carries a $10,000.00 fine and a 10 year jail term.
I, (we)__________________________________________ certify on this date ________________________________ that I (we) have read the Electronic Funds Transfer Affidavit and have no knowledge of and did not make or authorize the transaction (s) attached to this document

Cardholder Signature:_______________________________________ Date:_______/_________/__________


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