Dispute Card Transaction

Application

• Name of person disputing the transaction(s)?
  OK Name of person disputing the transaction(s)? is required
• Email Address
  OK Email Address is required
• Debit Card Number used in disputing transactions?
  OK Debit Card Number used in disputing transactions? is required
• Contact number of person disputing the transaction
  Optional OK Contact number of person disputing the transaction is required

• Did the cardholder authorize the transaction(s)?

  • Yes
  • No
  OK Did the cardholder authorize the transaction(s)? is required
• When did the cardholder notice the unauthorized transaction(s)?
  OK When did the cardholder notice the unauthorized transaction(s)? is required

• Has the cardholder given anyone permission to use their card?

  • Yes
  • No
  OK Has the cardholder given anyone permission to use their card? is required
• If Yes, please explain
  OK If Yes, please explain is required

• Has the cardholder contacted the merchant(s) about the transaction(s)?

  • Yes
  • No
  OK Has the cardholder contacted the merchant(s) about the transaction(s)? is required
• If Yes, what was the merchant's response?
  OK If Yes, what was the merchant's response? is required

• Did the cardholder receive any service or merchandise from the transaction(s)?

  • Yes
  • No
  OK Did the cardholder receive any service or merchandise from the transaction(s)? is required
• If Yes, what was received?
  OK If Yes, what was received? is required

• Has the cardholder made any internet purchases in the last six months?

  • Yes
  • No
  OK Has the cardholder made any internet purchases in the last six months? is required
• If Yes, please explain
  OK If Yes, please explain is required
• Please explain why you are disputing these transaction(s)
  OK Please explain why you are disputing these transaction(s) is required

Transaction 1

• Date
  OK Date is required
• Amount
  OK Amount is required
• Merchant Name
  OK Merchant Name is required

Transaction 2

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 3

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 4

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 5

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 6

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 7

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

Transaction 8

• Date

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050205120522053205420552056205720582059206020612062206320642065206620672068206920702071207220732074
  Optional OK Date is required
• Amount
  Optional OK Amount is required
• Merchant Name
  Optional OK Merchant Name is required

By clicking “Submit”, you attest that the transactions detailed above were not made or authorized by you or another person that you authorized to use your card. In addition, you attest that you received no benefit from the transactions being disputed. You give consent to Emblem Credit Union to release any information regarding your card and/or card account to any federal, state, or local 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 your card. You acknowledge that our investigation process is described fully for your reference in the agreement governing your account, which is available for viewing here: https://www.emblemcu.com/disclosures.html.
• OK is required