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Cardholder Dispute (Fraud)

For fraudulent use of a credit card, ATM, or debit card.

Form Instructions

Complete, print and sign this form, then mail, deliver, or fax it to:

Star One Credit Union
P.O. Box 3643
Sunnyvale CA 94088-3643
Attn: Card Services
Fax: (408) 543-5203

To submit this form electronically, log into Online Banking and select "Cardholder Dispute Form & Affidavit (Fraud)" in the "Forms" menu.

If you have any questions or concerns, call us and ask to speak with our Card Services Department.

Your Information
Date:
Email address:
Card Status:
Were you contacted by our Risk Management Department?

I have examined the charges made to my account and I am disputing the following charge(s) as neither I nor any person authorized by me to use my card, made the charge(s) listed below. In addition, neither I nor anyone authorized by me received goods and services represented by the transaction(s).

Transaction Information
Merchant Name/Terminal Location Posting Date Amount Disputed
Total Claim $

Explain the circumstances surrounding the fraud and list any additional disputed transactions:


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. Further, I understand I may be required to comply with a court order or subpoena to give testimony. I swear this affidavit is true and understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or imprisonment.

By completing and signing this form, I acknowledge that I have given a correct and true disclosure of the transaction I am disputing. I realize that Star One Credit Union may call upon me to supply additional supporting documentation to strengthen my claim against the merchant. I realize that not providing all details or exact information related to my dispute may delay the dispute resolution process.

___________________________________________
Member Signature
_______________________
Date