Fillable Affidavit for Unauthorized use of a Visa Debit (Inspirus Credit Union)

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Affidavit for Unauthorized use of a Visa Debit (Inspirus Credit Union)

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The Affidavit for Unauthorized use of a Visa Debit (Inspirus Credit Union) form is 2 pages long and contains:

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  • 96 other fields

Country of origin: US
File type: PDF

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Affidavit for Unauthorized use of a Visa Debit or ATM Card
Please complete this form if your Visa debit or ATM card has been used fraudulently.
As part of this process, your card will be deactivated.
If you’re disputing an authorized Visa debit transaction, please complete the Cardholder Dispute Form instead of this Affidavit.
If you’re disputing charges made on a Visa credit card, please call Cardholder Services at 1.866.820.4927.
Member Information
Member name (primary accountholder) Member name (joint accountholder)
Residence address City State ZIP
Account number Phone
( )
Card Information
Card number: Expiration date:
Lost Never Received Stolen Other
(Please explain circumstances.)
I first learned of the loss on ________________________ at __________________.
Date Time
I/we have reported the crime to the following law enforcement agency: ______________________,
on _________________. The case number is _____________________________.
Date
Circumstances
(When and how was the card lost or stolen, where, by whom, etc.? Please explain all details.)
I/We have reason to believe that ________________________________________ misused the referenced card. Said
person obtained possession of the card under the following circumstances. (Please provide details.)
I/We have reason to believe the referenced card is now in the possession of:
Name_____________________________________ Address:_________________________________________________
Phone_____________________________________ _________________________________________________
Unauthorized Charges/Withdrawal Information
The following ATM/Visa debit card purchases or withdrawals from my/our Checking/Savings account at
Inspirus Credit Union, a Division of Gesa Credit Union were not made, authorized, approved, or ratified
by me/us or such signers. (Please attach a sheet listing additional transactions, if necessary.)
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Date ____/____/____ Merchant’s name _________________________ Amount $________
Signature(s)
I/We have not received any part of the proceeds and will not benefit in any way, directly or indirectly, from the
fraudulent transactions made with my/our Card.
I/We authorize Inspirus Credit Union, a Division of Gesa Credit Union or any other victim of the actions
outlined above, to initiate criminal proceedings against the individual(s) that have defrauded my/our name.
If I/we at any time receive any restitution for this claim, I/we will promptly remit the funds to Inspirus Credit
Union, a Divison of Gesa Credit Union.
I/We recognize that false statements made in this affidavit with the knowledge of their falsity may subject me/
us to civil liability and criminal penalties.
Signature of primary accountholder Date
Signature of joint accountholder Date
Please fax the completed form to Credit Services: 206.676.3649
Please mail the original signed document to Credit Services: P.O. Box 576, Seattle, WA 98111-0576
The original signed document is needed for our records. Provisional credit can be issued based
on the faxed copy. Questions? Please call 206.628.6055 or 1.888.628.4010, ext 6055.
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Affidavit for Unauthorized use of a Visa Debit (Inspirus Credit Union)

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Completed 5 March 2021

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