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© 2017 Navy Federal NFCU 628A (6-17)
Navy Federal Debit Card/Business Debit Card Statement of Dispute
If available, please provide documentation to support your claim. Please read each category in its entirety and ensure you have provided
all available information. We may need additional information from you at various stages of your claim process. Please ensure your contact
information is correct.
A. Please complete each item in this section.
I have veried the charges to my account, and I dispute the following item:
B. Please check and complete the category that BEST describes your dispute.
I am not disputing this charge. I would like a copy of the sales receipt only.
Duplicate Charge
Cancellation
Were you advised of the cancellation policy?
Yes No
Returned Merchandise
If you have a credit slip or voucher or a refund acknowledgment that has not posted, please
provide date of credit slip.
Purchase Paid by Another Method
Cash Check Other credit/debit card Other
Date of First Charge (MM/DD/YY) Date of Second Charge (MM/DD/YY)
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Describe your attempt to resolve with the merchant, if applicable.
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Date of Cancellation (MM/DD/YY) Cancellation Number
Method of Cancellation
Merchant Name Date Contacted Merchant (MM/DD/YY), If Applicable
Posting Date (MM/DD/YY) Dollar Amount
$
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(If yes, please explain.)
Reason for Cancellation
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Date of Return (MM/DD/YY) Date Received by Merchant (if mailed)
Tracking Number
Shipping Company
Describe your attempt to resolve with the merchant.
Merchant’s Response
Date of Credit Slip (MM/DD/YY)
Cardholders Name: First MI Last Sufx
Debit Card Number Checking Account Number Access No.
Best Time to Be Reached Cell Phone No. Home Phone or Other Contact No.
Applicant Signature
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Date (MM/DD/YY)
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