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Cardholder Information
Dispute Information
Claim Circumstances
Merchants and Amounts
  • Cardholder Information

    • Card Type*
    • Card Closed*
      *Required for Unauthorized Use
  • Dispute Information

    Participation *

    Unauthorized Use

    I, the undersigned claimant declare, as appropriate that:

    I did not use, nor authorize anyone else to use, the ATM or Debit Card issued to me by Brokaw CU when said card was used to withdraw funds from my account at the Bank; or

    I did not receive any value or benefit from proceeds of the card transaction(s) and no proceeds were applied to any use or purpose on my behalf; or

    I have not arranged with the person(s) who misused the card to be reimbursed for proceeds of the card.

    Furthermore, I have made available all knowledge, ideas, or suspicions, if any, or the identity of the person who wrongfully used my card and will make available any such knowledge gained in the future and agree to assist and cooperate fully, without limitation, with any investigation pertaining to this matter, whether by federal, state, local, or bank investigators, including testifying before a grand jury or in a court of law against the party responsible for the improper or unauthorized use of the ATM or Debit Card. I hereby certify by signing below that the above information is true and correct.

    A FALSE DECLARATION TO A FEDERALLY INSURED FINANCIAL INSTITUTION MAY BE A VIOLATION OF FEDERAL AND/OR STATE LAW.

  • Claim Circumstances

    Customer Did Not Participate in Transaction(s) or Lost/Stolen

    • Is card still in your possession?*
    • Have you ever allowed anyone to use the card?*
    • Was the PIN/Secret Code number with the card?*
    • Was a police report filed?*

    Dispute with Merchant - Customer Originally Participated in Transaction(s)

    Any requested documentation is required for Visa to process your claim (i.e. receipts, proof of return, etc.)

    • Have you attempted to resolve your dispute with the merchant?*
      You must attempt to reach a resolution with the merchant before proceeding
    • Specify one
    • Please check the ONE category that best describes your dispute.

      Attach a copy of (a) the cash receipt, or (b) the front and back of canceled check, or (c) the copy of the other receipt.

      Attach a copy of sales slip or invoice.

      Attach a copy of the credit slip.

      • Attach a letter of explanation

      • Attach proof of return

      • Attach copies of correspondence with merchant.

      Attach corredpondence

    Supporting Documents

  • Merchants and Amounts

    Date * Merchant * Amount ($) *
      Totals:

    You should expect resolution or provisional credit in accordance with the provisions and disclosures set forth in your card agreement.


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