Debit Card Dispute

• Cardholder Information

  • Name or Organization Name*
  • Date*
  • Address*
  • Home Phone*
  • City*
  • State*
    Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
  • Zip*
  • Work Phone
  • Card Type*
    Debit Card ATM Card
  • Card Number*
  • Account Number*
  • Card Closed*
    Yes* No *Required for Unauthorized Use
  • Date Closed*

• Dispute Information

  Participation

  You did not originally participate in transactions or lost/stolen You did originally participate

  Unauthorized Use

  I, the undersigned claimant declare, as appropriate that:

  I did not use, nor authorize anyone else to use, the ATM or Debit Card issued to me by Gogebic County Federal Credit Union when said card was used to withdraw funds from my account at the Bank; or

  I did not receive any value or benefit from proceeds of the card transaction(s) and no proceeds were applied to any use or purpose on my behalf; or

  I have not arranged with the person(s) who misused the card to be reimbursed for proceeds of the card.

  Furthermore, I have made available all knowledge, ideas, or suspicions, if any, or the identity of the person who wrongfully used my card and will make available any such knowledge gained in the future and agree to assist and cooperate fully, without limitation, with any investigation pertaining to this matter, whether by federal, state, local, or bank investigators, including testifying before a grand jury or in a court of law against the party responsible for the improper or unauthorized use of the ATM or Debit Card. I hereby certify by signing below that the above information is true and correct.

  • Claimant's Signature* (type name)
  • Name of Organization (if applicable)

  A FALSE DECLARATION TO A FEDERALLY INSURED FINANCIAL INSTITUTION MAY BE A VIOLATION OF FEDERAL AND/OR STATE LAW.

• Claim Circumstances

  Customer Did Not Participate in Transaction(s) or Lost/Stolen

  • Please give a brief description of the circumstances of claim and conversation between merchant and cardholder.*
  • Is card still in your possession?*
    Yes No
  • If No, when was the card discovered missing?*
  • Have you ever allowed anyone to use the card?*
    Yes No
  • If Yes, who?*
  • Was the PIN/Secret Code number with the card?*
    Yes No
  • Who else had knowledge of the PIN/Secret Code number?
  • Was a police report filed?*
    Yes No
  • Case #
  • Police Department
  • Officer Contact Name

  Dispute with Merchant – Customer Originally Participated in Transaction(s)

  Any requested documentation is required for Visa to process your claim (i.e. receipts, proof of return, etc.)

  • Have you attempted to resolve your dispute with the merchant?*
    Yes No

    You must attempt to reach a resolution with the merchant before proceeding
  • Specific date of last contact
  • Specify one
    In person By phone By email
  • Supporting Documents
  • Who did you speak to?
  • What was said?
  • Please check the ONE category that best describes your dispute.
    I have no knowledge of the ATM withdrawal(s) listed below.

    The purchase was paid by check, cash, or other means but was still charged to my card

    Attach a copy of (a) the cash receipt, or (b) the front and back of canceled check, or (c) the copy of the other receipt.

    The amount I authorized differs from the amount that appears on my statement.

    Attach a copy of sales slip or invoice.

    I have received a credit slip from the merchant, however, credit has not appeared on my statement.

    Attach a copy of the credit slip.

    I did authorize the purchase, however:

    • I have not received the merchandise.
      Expected receipt date:
    • I have not received expected services.

      Attach a letter of explanation

    • The merchandise received was returned.
      Return date:

      Attach proof of return

    • I attempted to cancel purchase.
      Date of Attempt

      Attach copies of correspondence with merchant.

    The above item was billed monthly and I cancelled my service.

    Cancellation date:

    Attach corredpondence

    The purchase was a canceled hotel reservation.

    My cancellation number is:

    Attachments

• Merchants and Amounts

  Date	Merchant	Amount ($)
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  Date	Merchant	Amount
  	Totals:	Merchant Tools

  You should expect resolution or provisional credit in accordance with the provisions and disclosures set forth in your card agreement.

  For questions concerning your claim, please call 1-800-452-6045.