Member Name: ______________________________ _Address: ____________________________________ Best Number to call: __________________________ _

Member Number: _________________________________ City,State,Zip Code: _______________________________ Card Number: ____________________________________

Transactions have been posted to my account that I did not approve of , nor did I receive any proceeds or benefits from themerchant. Have you given your card or pin to anyone else to make purchases or withdrawals? Yes or No (check one)

My card was Lost or Stolen (check one) I noticed this on _________________ and called the credit union on __________________. I am still in possession of my card Yes or No (check one) I discovered the first non-fraudulent transaction on ____________________ and notified the credit union on

______________. My card is blocked?

Please list the non-fraudulent transactions below.

*A police report may be required to complete the process of your claim.

DATE/TIME MERCHANT/ATM LOCATION/ADDRESS AMOUNT

We can assist you with a dispute once you have contacted the merchant to resolve the issue. Mastercard requires that any dispute be resolved with the merchant first. If your dispute is not resolved with the merchant, we may be able to assist you. Inc lude dates, whom you spoke with and the phone number. Attach any related documentation needed to support your dispute.

I wish to dispute the charge for the reason listed below: Complete page 2 for all disputes. The merchant continues to charge my account. I canceled the service on _________________________. I did not receive the item or service I ordered.

I returned the item on ________________________ and received no refund as of today. (Enclose proof of return/receipt)

The merchandise was not as described. Please explain why on page 2. I paid for the transaction by an alternative method. (Enclose proof of payment) Duplicate Charge The amount charged to my account is incorrect. Please explain why on page 2. Other (Complete page 2)

CHECK CAR D/ATM CARD NO TICE OF DISPUTE OR ERROR - SECTION 1

STATEMENT OF DISPUTE - SECTION 2

Cancellation date for order (if applicable): _______________________________

Expected delivery date of merchandise: __

Card in question: (check one) ATM Debit Credit

Yes or No (check one)

RESOLUTION OF DISPUTE/RESOLUTION WITH MERCHANT - SECTION 3

1 What was purchased: _______________________________

_____________________________

Account in question: (check one) Savings Checking Credit Card

Date merchant contacted: _______________________________ Telephone #: ____________________________________

Whom you spoke with: _________________________________ Title: __________________________________________

Describe the attempt to resolve this dispute with the merchant and provide any communications with merchant regarding transaction:

(If more room is needed, please attach a separate sheet of paper)

First Contact Date: ____________________ Card Blocked: Yes or No Operator#: ___________________

WRITTEN STATEMENT OF FACTS - SECTION 5

CREDIT UNION USE ONLY - SECTION 7

SIGNATURES - SECTION 6

I participated in this transaction; however: I made an ATM withdrawal in the amount of $__________________ but only received $ __________________.

*Copy of ATM receipt is required.I made an ATM Cash Check deposit of $__________________.

Date: ___________ Time: ___________ Location/Address: _____________________________________ Amount: ___________

Attempted ATM Deposit for $___________ Actual Deposit $___________ Disputed Difference $___________

STATEMENT OF ATM ERROR OR MALFUNCTION - SECTION 4

2

I g ive my consent to the credit union to release any information regarding my card and/or card account to any state and/or

f ede ral law enforcement agency so that the information can be used in the investigation and/or prosecution of any person(s) th at may be responsible for the transaction inv olving my card and/or card account. I swear this cardholder dispute form is t rue an d accurate and that making a false sworn sta tement is subject to federal and/or state statutes and may be punishable by f ines and /or imprisonm .e nt.

Member signature: ____________________________________________ Date: _________________________________