Debit Card Dispute Form

CARDHOLDER INFORMATION

• Name of Member disputing the transaction(s)
  OK Name of Member disputing the transaction(s) is required
• Members Account Number
  OK Members Account Number is required

• Members Phone number

  - -
  OK Members Phone number is required
• Members E-mail
  OK Members E-mail is required
• Debit Card Number used in disputing transaction
  OK Debit Card Number used in disputing transaction is required

• Did the cardholder authorize the transaction(s)?

  • Yes
  • No
  OK Did the cardholder authorize the transaction(s)? is required

• When did the cardholder notice the unathorized transaction(s)

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900
  OK When did the cardholder notice the unathorized transaction(s) is required

• Has the cardholder given anyone permission to use their card?

  • Yes
  • No
  OK Has the cardholder given anyone permission to use their card? is required
• If Yes, please explain
  OK If Yes, please explain is required

• Has the cardholder contacted the merchant(s) about the transaction(s)? (Contact with merchant must be attempted)

  • No
  • Yes
  OK Has the cardholder contacted the merchant(s) about the transaction(s)? (Contact with merchant must be attempted) is required
• If Yes, please explain
  OK If Yes, please explain is required

• Did the cardholder receive any service or merchandise from the transaction(s)?

  • No
  • Yes
  OK Did the cardholder receive any service or merchandise from the transaction(s)? is required
• If Yes, please explain
  OK If Yes, please explain is required

• Has the cardholder made any internet purchases in the last six months?

  • No
  • Yes
  OK Has the cardholder made any internet purchases in the last six months? is required
• If Yes, please explain
  OK If Yes, please explain is required
• Please explain why you are disputing these transaction(s)
  OK Please explain why you are disputing these transaction(s) is required

Transaction 1

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072
  OK Date is required
• Amount
  OK Amount is required
• Merchant Name
  OK Merchant Name is required

Transaction 2

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 3

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 4

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072
  OK Date is required
• Amount
  OK Amount is required
• Merchant Name
  OK Merchant Name is required

Transaction 5

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072
  OK Date is required
• Amount
  OK Amount is required
• Merchant Name
  OK Merchant Name is required

Transaction 6

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072
  OK Date is required
• Amount
  OK Amount is required
• Merchant Name
  OK Merchant Name is required

By clicking “Submit”, you attest that the transactions detailed above were not made or authorized by you or another person that you authorized to use your card. In addition, you attest that you received no benefit from the transactions being disputed. You give consent to FFCU to release any information regarding your card and/or card account to any federal, state, or local law enforcement agency so that the information can, if necessary, be used in the investigation and/or prosecution of any person(s) who may be responsible for fraud involving your card.

• OK is required