Visa® Dispute Form

• Member Name *
• Account Number *
• Debit Card Number *
• Phone Number *
• Email *
• Is the card in your possession? *

  Yes No

Please note that if transactions were fraudulently posted to your account (your card or card number was stolen) we will block your current card and issue you a new card and PIN.

We must hear from you no later than 60 days after we sent the FIRST statement on which the problem or error appeared. If you do not tell us within 60 days after the statement was mailed to you, you may not get back any money you lost after the 60 days if we can prove that we could have stopped someone from taking the money if you had told us in time.

Transactions

Please list the transaction(s) you are wanting to dispute

Transaction #1

• Transaction Date
• Merchant Name
• Amount

Transaction #2

• Transaction Date
• Merchant Name
• Amount

Transaction #3

• Transaction Date
• Merchant Name
• Amount

Transaction #4

• Transaction Date
• Merchant Name
• Amount

• In your own words please thoroughly describe why you are disputing this (these) transaction(s).

If you have any questions please call our Bookkeeping Department at 773-328-7500 or 888-222-8571 ext.600