Debit/ATM Card Fraudulent Transaction Form

Transcription

1 Debit/ATM Card Fraudulent Transaction Form By signing this form you are affirming that you have examined all of the unauthorized transactions and in each instance you or any other authorized user did not: 1) originate the transaction, 2) authorize the transaction, or 3) receive any of the proceeds or benefits of any transaction(s) as reported below. If you have any doubt about whether you or another authorized user actually participated in the transaction(s) reported below, please do not sign this disclaimer. To declare a transaction(s) as unauthorized when you actually participated in the transaction(s) can void your claim and forfeit your dispute rights. You must be able to answer,, to the following 3 questions in order to submit a fraud form to The Summit: 1) Did you give or loan your card to anyone who made this purchase? 2) Did you voluntarily give your debit card number to anyone over the phone, or provide it on a mailed form or ? A Debit/ATM Card Disputed Transaction Form can be completed for any purchases made where a service or merchandise was paid for but never received, was returned, or the order was canceled. Additional documentation may be required. 3) Is the transaction a result of you signing up for a 'free trial' on the Internet that required you to use your debit card to pay for 'shipping only' or another similar charge? A Debit/ATM Card Disputed Transaction Form (Dispute form) can be completed for this type of transaction, if 1)the merchandise has been returned,and 2) you have a shipping company receipt to submit with the Dispute form. Member (please print): Member Address (Street address) Member Address (City, State and Zip) Member Contact Number: (best number to reach you, including Area Code) Debit/ATM Card Number: (please enter entire number) Member Account Number: Page 1 of 5

2 I have examined the transactions on my account and the following Debit/ATM transaction(s) was not authorized by me. Attach additional pages as necessary. Any fee(s) you incurred as a result of fraudulent transactions should be entered on the next page. Merchant Transaction Amount Transaction Total Dollar Amount of All Fraudulent Transactions $ Fee(s) you incurred as a result of the fraudulent transaction(s): Fee Amount Fee Type Fee Amount Fee Type Please provide answers to the following questions. 1. Are you currently in possession of your card? (If yes, skip to question #6) If no, was your card (please select only one option): Lost Stolen Card never received 2. If your card was lost or stolen, what date did you discover your card lost/stolen? 3. If your card was lost or stolen, please provide the date you reported the loss to the credit union? 4. If the card was not reported lost or stolen, please explain why you did not report the card missing to the credit union. 5. If your card was lost or stolen, please give a brief explanation below of how your card was lost/stolen/etc. Please provide location of where your card was lost/stolen Page 2 of 5

3 6. Was/Is your Personal Identification Number PIN attached or written on your card? 7. When and where did you last use your card? Merchant/Location 8. Do you know of any individuals who may be involved in these fraudulent transactions following information: Address Phone Number Relationship of individual to you 9. Has any individual(s) ever been previously authorized by you to use your card? following: Address Phone Number Relationship to you What authorization did you allow to the above individual? 10. Are you willing to press charges against any individual(s) who are found to be involved in the fraudulent transactions on your account? If you answer no and are unwilling to press charges against any individual(s) involved in the causing of a loss to your account, The Summit Federal Credit Union may pursue this issue and press charges against any individual(s) involved. 11. Have you filed a police report? following information: of Police Department Address of Police Department of Police Officer who took Report Police report filed Page 3 of 5

4 Crime Report Number of the Police Report 12. Other than yourself and any joint owner(s) on this account (if applicable), provide the names and relationships of other people living or working (i.e. contractor, home health aide) in your household. Relationship I give my consent to The Summit to release any information regarding my card and/or card account to any local, state and/or federal law enforcement agency so that the information can, if necessary, be used in the investigation and/or prosecution of any person(s) who may be responsible for fraud involving my card and/or card account. I swear the information provided in this form is true and understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or imprisonment. Member Signature Please complete and return this form to any Summit branch location or: Mail: Attention: Risk Management Department The Summit Federal Credit Union Canal Ponds Business Park 100 Marina Drive Rochester, NY Fax: (585) If you have any questions, please contact our Risk Management Department at (585) or (800) extension Please allow 10 business days for your documents to be reviewed, prior to inquiring on the status. Internal Use Only Page 4 of 5

5 Verification performed by Teller # Page 5 of 5