Standard Debit Fraudulent Dispute Form Visa Confidential Updated 06/08/16
FRAUDULENT TRANSACTION DISPUTE FORM PAGE OF
Name: Visa card number:
.
(that the transaction occurred on)
INSTRUCTIONS
Please note: this form is only to be used to dispute transactions that you believe to be fraudulent. A fraudulent transaction is one in which you did not authorize,
participate in, or benefit from. If you are disputing transactions that you do not consider to be fraudulent, please use the Cardholder Non-Fraud Transaction Dispute
Form. Include a separate sheet or letter if more room is needed for your explanation. If any of the below does not accurately reflect your dispute, please write a
separate letter and include all of the transaction information listed below
.
1. To submit a dispute using this form, please make sure that you complete all information. Any missing information will cause a delay in the processing of
your dispute.
2. The form can be completed by filling it out online or by hand and then printing it.
I certify that I did not use and that I did not authorize anyone else to use my card for the Disputed Transactions identified below. I also
certify that I did not receive any value or benefit in connection with the Disputed Transactions. I have made available below all information
and suspicions I have about the Disputed Transactions, including any information regarding the identity of the person who wrongfully used
my card for the Disputed Transactions. I authorize you to share the information with law enforcement, banking regulators and other third
parties in connection with any investigation of the Disputed Transactions, including any criminal investigation. I agree to cooperate in any
such investigation and in the prosecution of any person believed to be responsible for fraudulently using my card.
I certify that the information in this Fraudulent Transaction Dispute Form is true and correct.
_________________________________________________________ ________________________
Cardholder signature Date
I certify that my Visa card was:
* Institution The following transactions were not made by me or anyone authorized to use my Visa card.
use only:
Order Draft
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Date: Amount: Merchant:
Fraud: CARD PAGE OF
Counterfeit, card present (4)
Card still in my possession (6)
In the event additional charges are identified subsequent to the completion of this affirmation, I authorize my bank to add
those subsequent transactions to this affirmation.
