Dcecu.org

VISA® Check Card Statement of Disputed Items – Multiple Fraud
***$25.00 OR GREATER

Card Number: ________________________________ Case No: ____________________________________________
Cardholder Name: _____________________________________
Cardholder Address: ___________________________________
City State & Zip: ______________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
Tran Date: ____________ Tran Amount $____________ Merchant: __________________________________________
REQUIRED INFORMATION:

If the transaction was already reported to Visa Fraud what was the date it was reported? _____________
I am disputing the above charges due to the following reason (check only one reason):
_____ I have not, nor has anyone authorized by me engaged in this transaction.
My card was stolen on (date): __________ _____ I have not authorized or participated in this transaction in any way. My card has not been out of my possession. Page 1 of 2
Please provide specific details below or on a separate sheet of paper if needed. __________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ *** I give my consent to the credit union 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 this affidavit is true and understand that making a false sworn statement is subject to federal and/or state statues and maybe punishable by fines and/or by imprisonment.
Signature: _____________________________________________________ Date: _______________________________
Phone Number: _________________________________ Daytime Alternate Number: ____________________________
***Employee initials: _____________________

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We cannot stop or prevent a charge/authorized purchase from posting to an account; however, you may dispute
the charge/purchase once it is posted.
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* Written notification must be received within 60 days upon receipt of the first statement on which the charge(s)
appeared.
* Charges more than 120 days old are past the allowed charge back timeframe and are not normally allowable. If in doubt,
contact our Visa Department for clarification prior to completing this form.
* If requesting a copy of a charge receipt, we must allow the merchant up to 30 days to fulfill your request (45 days on
international purchases).
* You must allow 30 days for receipt of shipped merchandise unless the merchant stipulated a specific delivery date when
the order was placed.
* If you returned the merchandise to the merchant, you must allow the merchant 30 days, from the return date, to issue
credit to your account.
* In order to protect your dispute rights provided by Visa®, the purchase must have been processed through the Visa®
Network. Discrepancies with ATM/PIN transactions follow separate guidelines.
For internal use only:
What was the date the card was listed on the exception file? ________________
If you have any questions, please call (989) 835-7794 or (800) 835-7794. Please fax completed form to (989) 832-9295 or return to DCECU, P.O. Box 1649, Midland, MI 48641-1649. Page 2 of 2

Source: https://www.dcecu.org/pdf/rcenter/dcecuVisaCheckCardholderStatementOfFraud-gteq25.pdf