E-Teller In Branch Paper Statement Statement Visa Fraud Prevention Phone MSR. Other:

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2 Account Number: Last 4 Digits of Card: Card Fraud Questionnaire How did you discover the fraudulent transactions on your account? (Circle One) E-Teller In Branch Paper Statement Statement Visa Fraud Prevention Phone MSR Other: If Internet Fraud required: (For Verification purposes only, not used for correspondence) Does anyone else have access to your card or pin? YES NO If yes, who? Did you ever give your PIN number to anyone? YES NO If yes, who? Was your card ever out of your possession? YES NO If yes, when? Member Statement: If more space is needed, attach extra sheet. Was this loss reported to the Police Department? YES NO (If yes, fill in information below) Date Police Report Filed: / / Case Number: Police Department: Officer s Name: Phone Number: Member Signature: Date: Rev. 11/2013

3 PAGE OF FRAUDULENT TRANSACTION DISPUTE FORM Name: Visa card number: I certify that my Visa card was: Lost (0) Stolen (1) Card not received (2) Counterfeit, card present (4) Card still in my possession (6) * Institution use only: Order Draft The following transactions were not made by me or anyone authorized to use my Visa card. 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. Cardholder signature Date * Institution Use Only: Check transactions for which a draft should be ordered because of cardholder escalation. Required certification: We certify that our cardholder neither participated in nor authorized the referenced transaction(s). Issuer certifies account was closed Issuer certifies fraud was reported on DPS VROL Issuer certifies account was placed on the Exception File, with a pickup code on. If Applicable: Issuer certifies dispute was received via their Online Secure Banking Environment (if applicable) and that unique identity represents the cardholder s signature.

4 Additional Fraud: CARD PAGE OF

5 Claim Number Credit Union Bond Number Cardholder Dispute of Fraudulent Use of a Credit Card, Debit Card, or ATM Card Cardholder Information Cardholders Name Home Phone Work Phone Mailing address Street City State Zip Number of Cards Issued Card Number Was law enforcement Notified? Type of Card At the time of the Fraudulent transactions, my card was: Police report Number and Agency Debit Credit in my possession Lost Card #: ATM Card Never Received in the mail Stolen Card Visa Master Card Fraudulent Application Mail/Telephone Order/Internet Fraud Counterfeit Agency: Other ( ) Date Cardholder Discovered Loss Date Cardholder Reported Loss to Credit Union/Processor Date of First Fraudulent Transaction I complete this Cardholder Dispute From for the purpose of establishing the fraudulent use of my Credit/Debit/ATM Card(s). I did not give, sell or trade my card(s) to anyone nor did I give anyone permission to use my card(s). I have no knowledge that my spouse or minor child(ren) made any transaction(s) on or after the date of eth first fraudulent transaction indicated below. I did not receive any benefit from the unauthorized use of my Credit/Debit/ATM card(s). I did not use my card nor authorize the use of my card by anyone else after I discovered the unauthorized use of my card. I have examined all of the unauthorized transactions and in each instance I did not originate the transaction nor authorize it. Further, I did not receive proceeds or benefits from any of those transactions. Total amount of unauthorized transactions (itemized on the back of this page or an attached page(s)): $ Name and Address of unauthorized User (if known) Please provide details (if necessary) on a separate sheet Signatures I give my consent to the credit union to release any information regarding my card and/or card account to any local, state, and federal law enforcement agency so that 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 Cardholder Dispute Form is true and understand that making a false sworn statement is subject to federal and/or state statues and may be punishable by fine and/or imprisonment. Signed Date Co-Signer

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