EMPLOYEES FEDERAL CREDIT UNION

VISA CHECK CARD PURCHASE DISPUTE FORM DISPUTED ELECTRONIC FUNDS TRANSFER NOTIFICATION


Cardholder Name: ___________________________________________

Member#:_________________________________


Card Number: ______________________________


Cardholder Address: _______________________________________________


Cardholder Daytime Phone: (______ )___________________________

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.)



ERROR DESCRIPTION:


Police Report # ___________________



Did you notify police of the unauthorized use?YES NO



Where was the last ATM you used with your card? Date ______________________



Have you ever allowed anyone to use your card? If yes, who and when?YES NO



Was your PIN with the card?YES NO



Was your Personal Identification Number (PIN) written anywhere?YES NO



When did you discover your card missing? Date:____________________Time: __________________( _____A.M. _____P.M.)

Was your card lost or stolen? _______________



Cardholder Signature:_____________________________________ Date: __________________


If you claim that the ATM transaction was unauthorized, please answer the following questions and sign the Electronic Funds Transfer Affidavit.



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:______________


Download PDF version of Visa/ATM dispute form