Cardholder Credit & Debit Dispute/Fraud

Directions: Completely fill out and submit this form. If you prefer fax or email a PDF version of this form, click here to Download/Print a PDF.

Disputes must be filed within 90 days of the transaction posting.

Member Name on Account

Card Number

Member Number

Preferred Daytime Phone Number

Transactions to Dispute

You may dispute up to 3 transactions on this form.

Transaction #1 Merchant Name

Transaction #1 Date of Transaction

Transaction #1 Amount of Transaction

Transaction #2 Merchant Name

Transaction #2 Date of Transaction

Transaction #2 Amount of Transaction

Transaction #3 Merchant Name

Transaction #3 Date of Transaction

Transaction #3 Amount of Transaction

Total $ of Unauthorized Transactions

Please complete the section below that best describes the reason for submitting this claim.
• If FRAUD, please fill out a reason from the “Fraud Reasons” section.
• Or, if this is a MERCHANT DISPUTE, please fill out a reason from the “Dispute Reasons” section.
You may be contacted by the institution to obtain additional information. Failure to respond may result in your claim being denied.

FRAUD REASONS: Please note that in all cases of FRAUD, card will be closed immediately, and a new card will be issued.

– Select Fraud Reason

– My card was:

In my possession
Lost
Stolen

If Lost/Stolen, select the last date the card was in your possession:

DISPUTE REASONS: Before disputing charges, please make every effort to resolve with the merchant.

Please make a selection

– Posting Date

– Valid Transaction $ Amount