Dispute form

CARDHOLDER DISPUTE FORM

Step 1 of 7

14%

Last Four Digits of Debit Card Number(Required)

0 of 4 max characters

Cardholder Name(Required)

First Last

Cardholder Phone Number(Required)

Email(Required)

Disputed Amount $(Required)

Post Date(Required)

MM slash DD slash YYYY

Merchant Name(Required)

SIGNATURE REQUIRED(Required)

Before disputing a charge, please ensure you have made every effort to resolve the issue directly with the merchant.

Select Type of Dispute(Required)

Fraudulent Dispute

Non-Fraud Dispute

• Fraudulent Dispute (This is when you report a transaction you did not authorize or recognize, meaning someone else made the charge without your permission (e.g., stolen card, identity theft.) • Non-Fraud Dispute (This is when you made the transaction, but there is a problem with it, such as being overcharged, charged twice, or not receiving the product/service as promised.)

Fraudulent Dispute(Required)

Did not recognize

Please attempt to contact the merchant prior to disputing the charge.

When did the Cardholder contact the Merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

Non-Fraud Dispute(Required)

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

Cardholder certifies one transaction is valid, but posted more than once(Required)

Yes

All cards issued to me are in my possession(Required)

Yes

Valid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Invalid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

When did the cardholder contact the merchant?(Required)

MM slash DD slash YYYY

Reason for cancellation?(Required)

Date of cancellation(Required)

MM slash DD slash YYYY

Cancelation Number

Additional comment

What was ordered?(Required)

What was received?(Required)

Was merchandise suitable for the purpose intended?(Required)

Merchant’s response(Required)

File

Max. file size: 16 MB.

Additional comment

Please contact the merchant and notify us of the outcome.

When did the Cardholder contact the merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

What was the merchandise that was ordered?(Required)

What was the expected delivery date?

MM slash DD slash YYYY

Additional comment

I was overcharged for the purchase

Please include a copy of the signed sales receipt(Required)

Drop files here or

Max. file size: 16 MB.

Please provide details of your dispute(Required)

Other

Please provide details of your dispute(Required)

Please provide details of your dispute

Drop files here or

Max. file size: 16 MB.

Disputing more than one item?

Disputing more than one item?(Required)

Disputed Amount $(Required)

Post Date(Required)

MM slash DD slash YYYY

Merchant Name(Required)

SIGNATURE REQUIRED(Required)

Before disputing a charge, please ensure you have made every effort to resolve the issue directly with the merchant.

II Select Type of Dispute(Required)

Fraudulent Dispute

Non-Fraud Dispute

II Fraudulent Dispute

Fraudulent Dispute(Required)

Did not recognize

Please attempt to contact the merchant prior to disputing the charge.

When did the Cardholder contact the Merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

Non-Fraud Dispute

II Non-Fraud Dispute(Required)

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

I was billed twice for a single purchase

Cardholder certifies one transaction is valid, but posted more than once(Required)

Yes

All cards issued to me are in my possession(Required)

Yes

Valid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Invalid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Membership Cancellation

When did the cardholder contact the merchant?(Required)

MM slash DD slash YYYY

Reason for cancellation?(Required)

Date of cancellation(Required)

MM slash DD slash YYYY

Cancelation Number

Additional comment

Merchandise was returned

What was ordered?(Required)

What was received?(Required)

Was merchandise suitable for the purpose intended?(Required)

Merchant’s response(Required)

File

Max. file size: 16 MB.

Additional comment

I did not receive the merchandise

When did the Cardholder contact the merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

What was the merchandise that was ordered?(Required)

What was the expected delivery date?

MM slash DD slash YYYY

Additional comment

I was overcharged for the purchase

Please include a copy of the signed sales receipt(Required)

Max. file size: 16 MB.

Please provide details of your disput(Required)

Other

Please provide details of your dispute(Required)

Please provide details of your dispute

Max. file size: 16 MB.

Add one more dispute item?

Add one more dispute item?(Required)

Disputed Amount $(Required)

Post Date(Required)

MM slash DD slash YYYY

Merchant Name(Required)

SIGNATURE REQUIRED(Required)

Before disputing a charge, please ensure you have made every effort to resolve the issue directly with the merchant.

III Select Type of Dispute(Required)

Fraudulent Dispute

Non-Fraud Dispute

Fraudulent Dispute

Fraudulent Dispute(Required)

Did not recognize

Please attempt to contact the merchant prior to disputing the charge.

When did the Cardholder contact the Merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

Non-Fraud Dispute

III Non-Fraud Dispute(Required)

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

I was billed twice for a single purchase

Cardholder certifies one transaction is valid, but posted more than once(Required)

Yes

All cards issued to me are in my possession(Required)

Yes

Valid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Invalid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Membership Cancellation

When did the cardholder contact the merchant?(Required)

MM slash DD slash YYYY

Reason for cancellation?(Required)

Date of cancellation(Required)

MM slash DD slash YYYY

Cancelation Number

Additional comment

Merchandise was returned

What was ordered?(Required)

What was received?(Required)

Was merchandise suitable for the purpose intended?(Required)

Merchant’s response(Required)

File

Max. file size: 16 MB.

Additional comment

I did not receive the merchandise

When did the Cardholder contact the merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

What was the merchandise that was ordered?(Required)

What was the expected delivery date?

MM slash DD slash YYYY

Additional comment

I was overcharged for the purchase

Please include a copy of the signed sales receipt(Required)

Max. file size: 16 MB.

Please provide details of your disput(Required)

Other

Please provide details of your dispute(Required)

Please provide details of your dispute

Max. file size: 16 MB.

Add an additional dispute item?

Add an additional dispute item?(Required)

Disputed Amount $(Required)

Post Date(Required)

MM slash DD slash YYYY

Merchant Name(Required)

SIGNATURE REQUIRED(Required)

IV Select Type of Dispute(Required)

Fraudulent Dispute

Non-Fraud Dispute

Fraudulent Dispute(Required)

Did not recognize

Please attempt to contact the merchant prior to disputing the charge.

When did the Cardholder contact the Merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

IV Non-Fraud Dispute(Required)

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

I was billed twice for a single purchase

Cardholder certifies one transaction is valid, but posted more than once(Required)

Yes

All cards issued to me are in my possession(Required)

Yes

Valid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Invalid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Membership Cancellation

When did the cardholder contact the merchant?(Required)

MM slash DD slash YYYY

Reason for cancellation?(Required)

Date of cancellation(Required)

MM slash DD slash YYYY

Cancelation Number

Additional comment

Merchandise was returned

What was ordered?(Required)

What was received?(Required)

Was merchandise suitable for the purpose intended?(Required)

Merchant’s response(Required)

File

Max. file size: 16 MB.

Additional comment

I did not receive the merchandise

When did the Cardholder contact the merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

What was the merchandise that was ordered?(Required)

What was the expected delivery date?

MM slash DD slash YYYY

Additional comment

I was overcharged for the purchase

Please include a copy of the signed sales receipt(Required)

Max. file size: 16 MB.

Please provide details of your disput(Required)

Other

Please provide details of your dispute(Required)

Please provide details of your dispute

Max. file size: 16 MB.

Add another dispute item?

Add another dispute item?(Required)

Disputed Amount $(Required)

Post Date(Required)

MM slash DD slash YYYY

Merchant Name(Required)

SIGNATURE REQUIRED(Required)

V Select Type of Dispute(Required)

Fraudulent Dispute

Non-Fraud Dispute

Fraudulent Dispute(Required)

Did not recognize

Please attempt to contact the merchant prior to disputing the charge.

When did the Cardholder contact the Merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

V Non-Fraud Dispute(Required)

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

I was billed twice for a single purchase

Cardholder certifies one transaction is valid, but posted more than once(Required)

Yes

All cards issued to me are in my possession(Required)

Yes

Valid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Invalid Transaction(Required)

Post date(Required)

MM slash DD slash YYYY

Membership Cancellation

When did the cardholder contact the merchant?(Required)

MM slash DD slash YYYY

Reason for cancellation?(Required)

Date of cancellation(Required)

MM slash DD slash YYYY

Cancelation Number

Additional comment

Merchandise was returned

What was ordered?(Required)

What was received?(Required)

Was merchandise suitable for the purpose intended?(Required)

Merchant’s response(Required)

File

Max. file size: 16 MB.

Additional comment

I did not receive the merchandise

When did the Cardholder contact the merchant?(Required)

MM slash DD slash YYYY

What was the outcome of the merchant contact?(Required)

What was the merchandise that was ordered?(Required)

What was the expected delivery date?

MM slash DD slash YYYY

Additional comment

I was overcharged for the purchase

Please include a copy of the signed sales receipt(Required)

Max. file size: 16 MB.

Please provide details of your disput(Required)

Other

Please provide details of your dispute(Required)

Please provide details of your dispute

Max. file size: 16 MB.

Ukrainian Federal Credit Union

Personal and Business Banking & Financial Services

Dispute form

CARDHOLDER DISPUTE FORM

Please contact the merchant and notify us of the outcome.

I was overcharged for the purchase

Other

Disputing more than one item?

II Fraudulent Dispute

Non-Fraud Dispute

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

Add one more dispute item?

Fraudulent Dispute

Non-Fraud Dispute

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

Add an additional dispute item?

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other

Add another dispute item?

I was billed twice for a single purchase

Membership Cancellation

Merchandise was returned

I did not receive the merchandise

I was overcharged for the purchase

Other