Dispute For ATM/ Debit-Fraud Page______ of______
Phone Number:
Other:____________________________
Requested $ATM Dispense Partial Funds: Received $ _________
_____ Paid by Other Means
Canceled Transaction/Service: Date Canceled:_____________
Quality Issue: Detailed Description BelowUnauthorized
Transaction
Unauthorized Transaction
but, should have posted for $Incorrect Transaction Amount:
Transaction Posted for $ ______________ _________
Detailed Description BelowMerchandise not Received: Expected
Date for Delivery_____________
Detailed Description Below and Method _Merchandise Returned:
Returned Date _______________ ____________
Lost/Stolen
Transaction Amount $Merchant Name:Date: ____________
_______________________________ ________________
Transaction Amount $Merchant Name:Date: ____________
_______________________________ ________________
Transaction Amount $Merchant Name:Date: ____________
_______________________________ ________________
Transaction Amount $Merchant Name:Date: ____________
_______________________________ ________________
Transaction Amount $Merchant Name:Date: ____________
_______________________________ ________________
Card Holder Signature:____________________________________
Date:_______________
Duplicate processing
Address City, State Zip:
Date Attempted to Resolve with Merchant:____________
Member Explanation
Tri County Area FCU
Each dispute transaction must appear below. Use additional pages
if necessary.
Explain in detail why charges are being disputed. Use additional
page if necessary.
Member Information
Transaction Detail
At the time of the transactions. Where was the physical
card?
Disputed Transaction
Card Number:
In Possession
Card Holder Name:
ATM did not Dispense Funds
Credit not received
Teller #:___________
Member Number: _______________
Address City State Zip: Card Number: Other: but should have
posted for: Transaction Amount: Transaction Amount_2: Transaction
Amount_3: Transaction Amount_4: Transaction Amount_5: Explain in
detail why charges are being disputed Use additional page if
necessaryRow1: Signature1_es_:signer:signature: Check Box3:
OffCheck Box4: OffCheck Box5: OffCheck Box6: OffCheck Box7:
OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11:
OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15:
OffText16: Text17: Text18: Text19: Text20: Text21: Text22: Text23:
Check Box24: OffCheck Box25: OffDate_es_:date: Name: Phone Number:
Page: Pages: Date1: Date2: Date3: Date4: Date5: Merchant Name1:
Merchant Name2: Merchant Name3: Merchant Name4: Merchant Name5:
Teller #: Member Number:
