Debit/ATM Card Fraudulent Transaction Form
By signing this form you are affirming that you have examined all of the unauthorized transactions and in
each instance you or any other authorized user did not; 1) originate the transaction, 2) authorize it, or 3)
receive any of the proceeds or benefits of any transaction(s) as reported below.
If you have any doubt about whether you or another authorized user actually participated in the
transaction(s) reported below, please do not sign this disclaimer. To declare a transaction(s) as
unauthorized when you actually participated in the transaction(s) can void your claim and forfeit your
dispute rights.
You must be able to answer, “No,” to the 3 following questions in order to submit a fraud form to
The Summit:
1) Did you give or loan your card to anyone who made this purchase?
2) Did you voluntarily give your debit card number to anyone over the phone, or provide it
on a mailed form or email?
A Debit/ATM Card Disputed Transaction Form can be completed for any purchases
made where a service or merchandise was paid for but never received or was returned or
order canceled. Additional documentation may be required to be provided.
3) Is the transaction a result of you signing up for a 'free trial' on the Internet; however, it
required you to use your debit card to pay for 'shipping only' or another similar charge?
A Debit/ATM Card Disputed Transaction Form (Dispute form) can be completed for this
type of transaction, if 1)the merchandise has been returned, and 2) you have a
shipping company receipt to submit with the Dispute form.
Member Name (please print):
Member Address (Street address)
Member Address (City, State and Zip)
Member Contact Number: (best number to reach
you)
(
)
Debit/ATM Card Number: (please enter entire
number)
Member Account Number:
2.0416
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I have examined the transactions on my account and the following Debit/ATM transaction(s) was not
authorized by me. Attach additional pages as necessary. Any fee(s) you incurred as a result of
fraudulent transactions should be entered on the next page.
Has the transaction
Merchant Name
Transaction
Transaction
posted to the account?
Amount
Date
Yes
No
Total Dollar Amount of All
Fraudulent Transactions
$
Fee(s) you incurred as a result of the fraudulent transaction(s):
Fee Amount
Fee Type
Fee Amount
Fee Type
Please provide answers to the following questions.
Yes
No
1.Are you currently in possession of your card? (If yes, skip to question #6)
If no, was your card (please select only one option):
Lost
Stolen
Card never
received
2. If your card was lost or stolen, what date did you discover your card lost/stolen?
3. If your card was lost or stolen, please provide the date you reported the loss to the
credit union?
4. If the card was not reported lost or stolen, please explain why you did not report the card missing to the
credit union.
5. If your card was lost or stolen, please give a brief explanation below of how your card was lost/stolen/etc.
Please provide location of where your card was lost/stolen.
2.0416
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Yes
No
6. Was/Is your Personal Identification Number PIN attached or written on your card?
Merchant/Location
Date
7. When and where did you last use your card?
Yes
No
Yes
No
8. Do you know of any individuals who may be involved in these fraudulent transactions
If yes, please provide the
following information:
Name
Address
Phone Number
Relationship of
individual to you
9. Has any individual(s) ever been previously authorized by you to use your card?
If yes, please provide the
following:
Name
Address
Phone Number
Relationship to you
What authorization did you allow to the above individual?
10. Are you willing to press charges against any individual(s) who are found to be
Yes
No
involved in the fraudulent transactions on your account?
If you answer no and are unwilling to press charges against any individual(s) involved in the causing of a loss
to your account, The Summit Federal Credit Union may pursue this issue and press charges against any
individual(s) involved.
Yes
No
11. Have you filed a police report?
If yes, please provide the
Name of Police
following information:
Department
Address of Police
Department
Name of Police Officer
who took Report
Date Police report filed
Crime Report Number
of the Police Report
2.0416
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12. Other than yourself and any joint owner(s) on this account (if applicable), provide the names and
relationships of other people living or working (i.e. contractor, home health aide) in your household.
Name
Relationship
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 swear the information provided in this form 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.
Member Signature
Date
Internal Use Only
Verification performed by ___________________________________ Teller # ________
2.0416
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