Debit Card Dispute Request Form

							                                                                  Return Form To:           9 Law Drive           Tel: 800-297-2181
                                                                  Polish & Slavic FCU       P.O. Box 10425        Fax: 973-808-3212
                                                                  Attn: Card Servicing      Fairfield, NJ 07004   contact@psfcu.net



                                                               Debit Card Dispute Form
Date _______________________

Account # ________________________________ Card Number: _______________________________________________

Cardholder’s Name ________________________________________________________________
Please check the reason that applies and answer the items indicated: (Please use the back of this form to add comments)

         □     Duplicate Transaction (complete items 1 & 2 below)
         □     Double Charge (complete items 1 & 2)
         □     Non-receipt of Goods/Services (complete 1, 2 & 6 below)
         □     Cancellation of Service/Reservations (complete 1, 2, 3, & 4 below)
         □     Merchandise Returned; Credit not processed (complete items 2 & 4 below)
         □     Paid by Other Means (complete 1, 2 & 5 below)

    1.   How and when was the dispute/unauthorized transaction discovered? _____________________________________________
         _______________________________________________________________________________________________________________
         _______________________________________________________________________________________________________________


    2.   Was an attempt made to contact the merchant for resolution?
         Yes: Spoke with ____________________________________________________ On (date) ___________________________________
         Merchant’s response: ____________________________________________________________________________________________
         No: Reason merchant not contacted _______________________________________________________________________________

    3.   Provide the following information for cancelled services/reservations:
         Date of cancellation _________________________ How was the merchant notified?___________________________________
         Spoke with ________________________________________ Cancellation # _______________________________________________
         Reason for cancellation _________________________________________________________________________________________

    4.   Provide the following information for merchandise return:
         Date of return ____________________________ Method of return _______________________________________________________
         Name of shipping company ________________________________ Ship/Track # __________________________________________
         (If possible, please provide a receipt for proof of return.)


    5.   If payment was made by other means, please indicate other method: ______________________________________________
         (Please provide copy of check, receipt, or copy of statement from another card.)

    6.   For non-receipt of goods/service, please provide the following information:
         What was purchased?
         __________________________________________________________________________________________

         What was the expected date of receipt for the merchandise/services? _______________________________________________


Card Servicing – v. 7.28.09                                                                                             Page 1 of 2
Cardholder Explanation Section (In English):

16 Digit Card Number _________________________________________________________________________________________

Cardholder Statement: _______________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

1.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

2.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

3.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

4.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

5.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

6.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

7.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

8.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

9.       Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________

10.      Transaction Date ______________ Amount $ _______________ Merchant’s Name ____________________________


If you need more space to enter additional transactions or comments, please use a separate page, make a note that more information is
provided on next page, sign both pages and attached them to the Card Dispute Form.



X____________________________________                                       Date: ____________________________________
           (Member Signature)
___________________________________________________________________________
For Office Use Only:

Dispute Received by: ________________________________________           Branch: ________________________________________
                                   (Employee Name)


 




Card Servicing – v. 7.28.09                                                                                                Page 2 of 2