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> Fraud occurs when a transaction clears your account and you did not authorize, request, or initiate the transaction.> A Dispute is when you requested or initiated the transaction but there is a problem or error with the transaction.>

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State Zip

The following transaction(s) are in question:Transaction Type

*Debit Card W/D *POS W/D *ATM W/D

Date Cardholder Discovered Loss _____ /_____ /_____ Date Reported Loss to Credit Union _____ /_____ /_____In My Possession LostNever Received Stolen

Was PIN with Card? ________ Was PIN given out? ________ To whom? ____________________________________

Name and Address of Unauthorized User (if suspect is known) ________________________________________________

- Fraudulent charges that occur utilizing the cardholders PIN # are subject to $50 member's liability. For signature based transactions you are subject to $0.00 liability.

- If the fraudulent charge occurred local to the cardholder's address or was processed using the cardholders PIN # please forward a copy of the full police report.

Complete ONE of the following sections (Section III for Fraud Transactions or Section IV for Dispute Transactions), and then complete Section V.

Debit Card Transaction Fraud/Dispute Form

Part I Your Contact Information

Part III Fraud Transactions

At The Time of the Fraudulent Transactions, my Card was: (Select One)

We cannot stop a pending charge; however, once the transaction posts VISA extends billing rights to cardholders. To preserve these billing rights, the cardholder must notify Jax Federal Credit Union within sixty (60) days from the closing date of the statement on which the error first appeared.You may be contacted during the processing of your claim for information. Please be sure contact information below is correct and be prepared to respond promptly to any request for information. Failure to do so will result in delayed processing of your claim and awarding refunds.

Transaction Date (mm/dd/yy)

Part II Transaction Details (Review Transaction History to complete this section)

Merchant Name/LocationAmount from

Transaction History

Cell Phone Work Phone

Email Address

Street Address City

Home Phone

Important

To report a fraudulent or disputed transaction you will need to complete the following five sections of this three page form. When applicable, we will provide a provisional credit within ten business days; however the entire process can take up to 90 days to investigate.

I did not authorize the transaction(s) - I certify that I did not authorize or participate in the transaction(s) with the merchant, nor did I receive proceeds or benefits from any of the transaction(s). I have examined all of the unauthorized transaction(s) and in each instance I did not originate the transaction nor did I give, sell, or trade my card to anyone. I have not given permission to anyone to use my card and I am willing to prosecute.

Cardholder Name Card Number Member Number

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

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Date Merchant was Contacted _____ /_____ /_____ Name of Representative _____________________________Use this section to provide a detailed explanation of your dispute and the outcome of the contact, if necessary.

Select One Dispute Reason Below:1. The ATM transaction listed is incorrect. Amount Requested $ __________ Amount Received $ __________

2. I was charged the wrong amount. My receipt shows $ ____________. (Please attach a copy of your sales receipt.)3. My account was charged twice for the same transaction. I authorized only one charge with the merchant for

$ ____________. (Please attach a copy of your sales receipt.)

4. I was issued a credit which did not post to my account. (Please attach a copy of your credit slip.)

5. I used another form of payment (cash, check, credit/debit card) for this transaction. (Please attach a copy of

your proof of alternate payment.)

6. I cancelled a subscription/membership/policy (circle one), prior to the transaction date, however it was still

charged to my account. (Please attach a copy of the letter, email, or fax requesting the cancellation and/or

a copy of your contract.)

- Date you contacted the merchant to cancel? _____ /_____ /_____ Cancellation # ____________________

7. I cancelled a reservation, prior to the transaction date, however I was still charged for it.

- Date you contacted the merchant to cancel? _____ /_____ /_____ Cancellation # ____________________

8. I authorized the transaction however I have since returned the merchandise and have not received a credit

from the merchant. (Please attach proof of return, return receipt, or credit slip)

9. I authorized the transaction however I have not received the merchandise.

- What was the expected delivery date? _____ /_____ /_____

10. I authorized the transaction however I am disputing the quality of the service that was provided. (Please attach

supporting documentation, such as contracts, repair bills, or copies of second opinions from a certified

merchant on their invoice or letterhead.)

11. Other - Explain in detail on a separate sheet.

Cardholder Signature ___________________________________ Date ____________________

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. I agree to fully assist and cooperate with any investigation and/or prosecution of such persons and swear that the information that I have provided above is true and correct.

I did authorize the transaction(s) - I certify that I did authorize or participate in the transaction(s) with the merchant. However; this transaction(s) includes an error selected from the options below. I have made an effort to resolve the situation with the merchant and the merchant has not corrected the error. If applicable I did return disputed merchandise using a traceable shipping method (UPS, Federal Express, DHL, US Postal Service).

Part IV Dispute Transactions

***Attach a separate sheet i you need more space.***

Part V Cardholder Signature RequiredThe signature of the cardholder must be in this section with the date to prevent a delay in processing.

0.00 0.00

0.00

0.00

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Fax:To: From:

Fax: Pages:

Re: Fraud/Dispute Form Date:

Check List for Debit Card Fraud/Dispute Form

1. Completed Debit Card Fraud/Dispute Form

2. Supporting Documentation, specified on dispute form

- Police Report - Proof of Alternate Payment

- Sales Receipt(s) - Cancellation Communication

- Credit Slip - Contract

- Proof of Return - Other Documentation

3. Mail or Fax Form to:

JAX Federal Credit Union

Attn: Debit Card Services

562 Park St

Jacksonville, FL 32204

Fax: (904) 357-3503

3. Contact Debit Card Services with any questions

(904) 475-8081 OR (904) 475-8000

4. Once we receive all the necessary documentation, it can take up to 90 days to investigate your claim. If a provisional credit is warranted it will be provided as soon as possible but no later than 10 business days.

If you received this fax in error, please contact the sender at JAX Federal Credit Union at (904) 475-8000.

The following facsimile is intended for the above referenced recipient only.

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Debit Card Services

904.357.3503