Debit Card Dispute

First Name

Middle Initial

Last Name

Suffix

Card Number

Member Number

Preferred Contact Number

Current Address:

Address Line 1

Address Line 2

City

State

Zip Code

Please thoroughly read this entire form, then choose the ONE category that best describes your dispute:

Please select the best option:

Disputed Transactions:

Merchant Name

Date

Amount

Merchant Name

Date

Amount

Merchant Name

Date

Amount

Merchant Name

Date

Amount

Merchant Name

Date

Amount

Merchant Name

Date

Amount

Details of the above dispute(s):

Acknowledgments and Signatures:

I understand this forgery and/or use without my consent is subject to investigation by local, state, and/or federal law enforcement agencies. I may be required to comply with a court order or subpoena to give testimony. I further understand and authorize Card Client Services to act on my behalf to resolve this report of fraudulent transactions.

I understand that knowingly making a false sworn statement is subject to federal and state statutes and may be punishable by fines and imprisonment.

I declare under penalty that the information I have provided herein is true and correct and I will testify, declare, depose, or certify to the truth hereof before any competent tribunal, officer, or person in any case now or hereafter pending in connection with the matters contained within this declaration.

Full Name

Date

I agree and understand that by checking the box below, I acknowledge and consent that the above typed name is my electronic signature. This electronically typed signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.

Yes, I agree and accept this information concerning my digital signature.

312 N 4th Ave

(812) 424-9396

Mon - Fri: 9:00 - 5:00

Debit Card Dispute

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