Debit Card Dispute Form

Cardholder Information

Dispute Information

Claim Circumstances

Merchants and Amounts

Cardholder Information
- Name or Organization Name*
- Date*
- Primary Phone*
- Address*
- City*
- State*
- Zip*
- Card Type*
  Debit Card
- Card Number*
- Account Number*
- Card Closed*
  Yes* No *Required for Unauthorized Use
- Date Closed*
Dispute Information

You did not originally participate in transactions or lost/stolen You did originally participate

Unauthorized Use

I, the undersigned claimant declare, as appropriate that:

I did not use, nor authorize anyone else to use, the Debit Card issued to me by Wailuku Federal Credit Union when said card was used to withdraw funds from my account at the Bank; or

I did not receive any value or benefit from proceeds of the card transaction(s) and no proceeds were applied to any use or purpose on my behalf; or

I have not arranged with the person(s) who misused the card to be reimbursed for proceeds of the card.

Furthermore, I have made available all knowledge, ideas, or suspicions, if any, or the identity of the person who wrongfully used my card and will make available any such knowledge gained in the future and agree to assist and cooperate fully, without limitation, with any investigation pertaining to this matter, whether by federal, state, local, or bank investigators, including testifying before a grand jury or in a court of law against the party responsible for the improper or unauthorized use of the Debit Card. I hereby certify by signing below that the above information is true and correct.
- Claimant's Signature* (type name)
- Name of Organization (if applicable)
A FALSE DECLARATION TO A FEDERALLY INSURED FINANCIAL INSTITUTION MAY BE A VIOLATION OF FEDERAL AND/OR STATE LAW.
Claim Circumstances
Customer Did Not Participate in Transaction(s) or Lost/Stolen
- Please give a brief description of the circumstances of claim and conversation between merchant and cardholder.*
- Is card still in your possession?*
  Yes No
- If No, when was the card discovered missing?*
- Have you ever allowed anyone to use the card?*
  Yes No
- If Yes, who?*
- Was the PIN/Secret Code number with the card?*
  Yes No
- Who else had knowledge of the PIN/Secret Code number?
- Was a police report filed?*
  Yes No
- Case #
- Police Department
- Officer Contact Name
Dispute with Merchant - Customer Originally Participated in Transaction(s)

Any requested documentation is required for Visa to process your claim (i.e. receipts, proof of return, etc.)
- Have you attempted to resolve your dispute with the merchant?*
  Yes No
  You must attempt to reach a resolution with the merchant before proceeding
- Specific date of last contact
- Specify one
  In person By phone By email
- Who did you speak to?
- What was said?
- Please check the ONE category that best describes your dispute.
  
  I have no knowledge of the ATM withdrawal(s) listed below.
  
  The purchase was paid by check, cash, or other means but was still charged to my card
  Attach a copy of (a) the cash receipt, or (b) the front and back of canceled check, or (c) the copy of the other receipt.
  
  The amount I authorized differs from the amount that appears on my statement.
  Attach a copy of sales slip or invoice.
  
  I have received a credit slip from the merchant, however, credit has not appeared on my statement.
  Attach a copy of the credit slip.
  
  I did authorize the purchase, however:
  
  I have not received the merchandise.
  Expected receipt date:
  
  I have not received expected services.
  Attach a letter of explanation
  
  The merchandise received was returned.
  Return date:
  
  Attach proof of return
  
  I attempted to cancel purchase.
  Date of Attempt
  
  Attach copies of correspondence with merchant.
  
  The above item was billed monthly and I cancelled my service.
  Cancellation date:
  
  Attach corredpondence
  
  The purchase was a canceled hotel reservation.
  My cancellation number is:
- Supporting Documents File 2

Merchants and Amounts

Date	Merchant	Amount ($)

























	Totals:

You should expect resolution or provisional credit in accordance with the provisions and disclosures set forth in your card agreement.

Online Banking

Cardholder Information

Dispute Information

Unauthorized Use

Claim Circumstances

Customer Did Not Participate in Transaction(s) or Lost/Stolen

Dispute with Merchant - Customer Originally Participated in Transaction(s)

Merchants and Amounts