Please fill out form completely and fax back to Dispute Department at: (248) 250-5409 KEEP ORIGINAL AT BANKING CENTER BANKING CENTER NO/CONTACT NAME / PRIMARY CHECKING ACCOUNT NO CARD NUMBER DOLLAR AMOUNT TRANSACTION DATE POSTING DATE MERCHANT NAME EMAIL ADDRESS
VISA DEBIT CARD STATEMENT OF DISPUTE
CARDHOLDER NAME CARDHOLDER ADDRESS CITY, ST ZIP CODE , DAYTIME PHONE NO ( ) EVENING PHONE NO ( ) -
I am disputing the above charge due to the following reason (check only one):
I have not, nor has anyone authorized by me engaged in this transaction. My card was reported (check one): Lost Stolen on (date) . . The correct amount is $ .
The amount billed is incorrect. I have enclosed my copy of the sales slip dated I am disputing the following charges for lodging for $ I am disputing the following charges for vehicle rentals for $ . See details below.
. I returned the vehicle on (date)
. See details below. via phone/in writing.
The merchant continues to charge my account for a recurring payment that I canceled on (date) I have (check one): Returned Attempted to return the merchandise on (date) The merchant refused to (check one): Adjust the price .
Repair or replace the goods or other things of value
Issue a credit -orSee details below. (Please enclose proof of return if available). I have engaged in the transaction listed & have contacted the merchant in an attempt to resolve the dispute. The delivery day was to be -orI canceled the order on (date) & was not credited. The merchandise shipped arrived broken or unable to be used for the purpose sold. See details below. I have (check one): Returned -orAttempted to return the merchandise & I contacted the merchant on (date) to attempt to resolve this to no avail. (Please enclose a copy of the shipping receipt, if applicable.) I contracted with the merchant for services (described below) to be provided on (date) . I have not received them. I have contacted the merchant in order to resolve the dispute to no avail. I participated in one transaction at the merchant location, but NOT the transaction listed. I, or someone authorized by me, was in possession & control of all cards at the time of the transaction. The authorized transaction amount is $ on (date) . The charge listed was a single transaction but has posted times to my account.
I am disputing the listed ATM cash withdrawal. I have explained the details below. I have not authorized or participated in any way in this transaction. My card has not been out of my possession. Dispute must be filed no later than 60 days after Flagstar Bank sent the first statement on which the problem or error appeared. Please provide specific details as to how you think your card may have been compromised (i.e. victim of internet phishing, lost or stolen belongings, victim of fraud or larceny). Please send additional paper as necessary.
CARDHOLDER SIGNATURE รป
DATE
11/07