VISA Check Card Dispute Form

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1 * indicates a required field VISA Check Card Dispute Form The Visa Check Card Dispute Form should be completed if you have initiated a debit card transaction with a merchant and are now disputing the transaction. (Do not choose this form for unauthorized transactions. If someone used your card to make a transaction without your knowledge or permission, a Cardholder Claim of Fraud must be completed. The card must be closed to prevent additional fraud from occurring.) The cardholding member must be the person who completes this form. Instructions: Once you have completed this form, please provide all supporting documentation to NSWC Federal Credit Union by one of the following methods: Deliver to any branch or Fax to Attn: Card Services Resources Disputes Mail to NSWC Federal Credit Union P.O. Box 519 Dahlgren, VA *Name: *Card number: *Day Phone: *Transaction Date: *Merchant Name: *Transaction amount: *Dispute amount: BY SUBMITTING THIS FORM AT THE END OF THIS DOCUMENT I DECLARE THE INFORMATION PROVIDED ON THIS FORM IS TRUE AND CORRECT Depending on the transaction type, Visa may require you to try to resolve the dispute directly with the merchant. For credit transactions, those not conducted using a PIN, Visa requires you first attempt to resolve the dispute directly with the merchant before submitting the dispute. The attempt to resolve must be after the charge has posted. This form or notice of your dispute must be received by NSWC Federal Credit Union within sixty (60) days after the statement including this transaction was mailed to you. The required fields per dispute are marked with an asterisk (*). Please fill in the following appropriate section that most closely matches your dispute type. Please provide as much detail as possible, attach any supporting documents and attach a separate sheet if more space is needed for your explanation.

2 Cancellation (recurring transaction, i.e., subscription, membership, policy) Were you advised of any cancellation policy? Yes No (if yes, explain below) *Date cancelled with merchant: (cannot be used as an attempt to resolve date) *Cancelled by means of: phone (spoke with ) (provide copy) *Cancellation number: Cancellation (hotel reservation) Were you advised of any cancellation policy? Yes No (if yes, explain below) *Date cancelled with merchant: (cannot be used as an attempt to resolve date) *Cancelled by means of: phone (spoke with ) (provide copy) *Cancellation number:

3 Return merchandise dispute *Date returned: Date received by merchant: If returned by mail, Return Merchandise Authorization Number (RMA) *Shipping Company: Tracking Number: *Reason for return: If you have a credit slip, voucher or a refund acknowledgement that has not posted please provide: *Date of credit slip: Invoice/receipt number of the credit: I was charged multiple times for the same transaction *Date for the first charge: *Date of second charge: *Date of third charge: *Date of fourth charge: *Describe your attempt to resolve with the merchant & merchant & the date(s) of contact: Incorrect transaction amount *The amount of this transaction posted for but should have posted for Note: You must supply a copy of your receipt showing the correct amount.

4 Non-receipt of goods or services Merchandise or services not received. Expected delivery date: Merchant unwilling or unable to provide service. *Describe attempt to resolve with the merchant & the date(s) of contact Paid for goods or services by other means Check Cash Other Bank Credit Card Other: *Describe your attempt to resolve with the merchant & date(s) of contact: Note: You must supply a copy of proof of other means of payment. Proof can include a copy of the front and back of a canceled check, a cash receipt or another Bank Card Statement. A credit transaction posted as a debit in error *A credit transaction for was posted to my account as a debit transaction. Note: You must supply a copy of the credit receipt received from the merchant.

5 All Other Disputes (do not choose this option for unauthorized transactions. If someone used your credit card or debit card to make transaction(s) without your knowledge or permission, an Affidavit of Fraud must be completed. The card must be closed to prevent additional fraud from occurring). Please explain below: