Fill - Free fillable Debit Card Dispute/Fraud Questionnaire PDF form

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Debit Card Dispute/Fraud Questionnaire

Member Name: __________________________________________

Last 4 of card number: __________

Transaction Merchant and Amount _________________________________________________

(If more than one, please attach a list of all unauthorized transactions.)

Circle Yes or No to the questions below:

Is the debit card currently in your possession? YES NO

If no, have you reported the card lost/stolen? YES NO

Have you ever lost or misplaced your card? YES NO

Have you previously given someone permission to use your debit card number? YES NO

Could someone in your household have used your card without your knowledge? YES NO

Have you previously conducted business with the merchant? YES NO

Do you have an account with the merchant? YES NO

Did you accept terms and conditions with the merchant? YES NO

Did you sign up for a free trial that required cancelation to prevent further charges? YES NO

Is the transaction(s) under $20.00? YES NO

Have you attempted to resolve this directly with the merchant? YES NO

If No, you MUST contact the merchant ﬁrst. Failure to contact the merchant can delay your dispute and,

in some cases, result in the denial of your claim.

If Yes, what were you told by the merchant?

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Please verify your contact information below. (You may receive correspondence that will require answering

further questions regarding the dispute. Failure to respond to the letter, email, or phone call could result in the

denial of your claim.):

Email - _______________________________________________

Phone Number - ________________________________________

PLEASE READ - What you need to know about disputing charges:

If the dispute/fraud claim is accepted, your account will be issued a provisional credit within 10 business

days of receipt of completed dispute/fraud paperwork, and you will receive a letter notifying you of the

provisional credit.

If the dispute is denied by the merchant, the provisional credit will be withdrawn from your account. You

will receive a letter notifying you of the denial along with identifying information regarding the

transaction from the merchant. Merchants have up to 45 days to issue a merchant rebuttal. You will

need to contact the merchant if you still believe the transaction(s) to be unauthorized.

If you receive restitution for monies already issued to you by Mil-Way Credit Union, please contact us

immediately. If the credit union receives notiﬁcation of any merchant credit(s), we will remove our

credit(s) immediately.

Multiple false disputes could result in termination of services (debit cards or draft accounts).

If you have any questions about the dispute/fraud process, please contact the Member Services

Department at 870-772-0661.

I have read and understand the "Debit Card Dispute/Fraud Questionnaire" and answered the questions

truthfully to the best of my ability.

SIGNATURE AND DATE

MEMBER SERVICE REPRESENTATIVE

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