Visa Debit Cardholder Dispute Form
Before disputing a charge with Inspirus Credit Union, you must make an effort to resolve the dispute with the
This form is to be completed only if the disputed Visa debit card transaction was initiated by the cardholder. If the
card is lost or was stolen or if the transaction was initiated without the cardholder’s knowledge or consent, the card will
need to be deactivated. Please complete an Affidavit of Unauthorized Use instead of this form.
If you are disputing a transaction on your credit card, please call
Cardholder Services at 1-800-654-7728.
(This form may be used for Visa
card disputes only.)
Member number ________________ Name _____________________________________________________
Daytime phone ( ______ ) ______-______ E-mail address_____________________@___________________
Merchant _________________________ Disputed amount $____________ Transaction date ____/____/____
Reason for Dispute
I do not recognize the charge. You may need to complete an Affidavit of Unauthorized Use and deactivate
the card.
Duplicate transaction. The transaction was posted two or more times to the account. Only one charge was
I was
vercharged for the purchase Credit posted as a sale Credit did not post to my account
Please attach a copy of the original transaction receipt and any credit transaction receipt for the above reasons.
Membership cancellation. Please enclose a copy of the letter, e-mail, or fax requesting cancellation.
On what date did you contact the merchant to cancel? ____/____/____ Cancellation # ______________
Why did you cancel the membership? ____________________________________________________
Were you advised of a cancellation policy?
Yes No
If yes, what is the merchant’s cancellation policy? __________________________________________
Merchandise was returned. Please attach proof of return or credit slip.
What was ordered? _____________________________ What was received?_____________________
Was the merchandise suitable for the purpose intended?
Yes No
Why did you return merchandise? _______________________________________________________
I did not receive the merchandise.
What was the expected delivery or pickup date? _____/_____/_____
What merchandise was purchased? ______________________________________________________
Paid by other means. If the purchase was paid by another financial institution, you’ll need to provide a
copy of the canceled check (front and back) or a billing statement from the credit card or debit card. If the
purchase was paid by cash, you’ll need to provide a copy of the cash receipt.
The hotel room charge was posted to my account after I canceled. (A cancellation number is required.)
Were you advised of the hotel’s cancellation policy?
Yes No
If yes, what is its policy?________________________________________________________________
Cancellation number (required) _________________________ Cancellation date ____/____/____
Quality of service dispute or other. Using the space below or on an attached sheet of paper, please
describe your dispute and your attempts to resolve the matter with the merchant. Please include supporting
documentation, such as repair bills, contracts, or copies of neutral third-party opinions from a certified
merchant written on his or her invoice or letterhead.
Have you tried to contact the merchant to resolve the problem? Yes
If yes, date merchant was contacted ____/____/____ Name of representative____________________________
What was the outcome of your contact?__________________________________________________________
Please sign this form to prevent any delay in processing. Thank you!
Signature_________________________________________________ Date_____/_____/_____
Fax completed form to Credit Services: (206) 676-3649, or
Mail completed form to Credit Services: P.O. Box 576, Seattle, WA 98111-0576
Questions? Please call (206) 628-6055 or 1-888-628-4010, ext. 6055
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