Fraudulent Transaction Dispute Form - NASA Federal Credit Union

CARD _____________________ PAGE____OF____
Fraudulent Transaction Dispute Form
Use this form to report unauthorized (fraudulent) transactions for Signature, ATM or PIN Point Of Sale (POS) transactions using your NASA Federal
Visa Check Card or ATM Card without your knowledge or consent.
Important Things To Know:
Please use black ink.
In order to prevent further unauthorized transactions, your NASA Federal Check Card or ATM Card must be blocked. To have your card
blocked, call 301-249-1800, ext. 333 during normal business hours. After hours, call 1-866-708-9364, option 2.
A new Card and PIN may be obtained by visiting a participating Instant Issue branch* (Check Card & HSA card only), or a new Card and
PIN can be ordered and mailed to the address on file. Cards and PINs mailed to the address on file may take up to 10 days to receive.
NASA Federal will re-credit your account promptly upon receipt of the completed required form.
Return the completed Fraudulent Transaction Dispute Form in person at any branch office, by fax 301-390-4524 or by mail to:
NASA Federal Credit Union
Attn: Debit Card Department
PO Box 1730
Bowie, MD 20717-1730
If you need assistance or have any questions completing these forms, please contact us on 301-249-1800 or 1-888-NASA-FCU (627-2328) ext.333.
Credit Union Account #: Visa Check/ATM Card Number: Daytime phone #:
Your name (please print):
Your address:
I state to the best of my knowledge that the above-referenced Visa Check, ATM Card was:
PLEASE MARK ONLY ONE APPROPRIATE SELECTION:
__ Lost: Date Card Lost ______/______/______ Check/ATM Card has been lost. I have not used the Check/ATM Card
identified above for the purchase of merchandise, services, cash or for any other purpose since the above date.
__ Stolen: Date Card Stolen ______/______/______ Check/ATM Card has been stolen. I have not used the
Check/ATM Card identified above for the purchase of merchandise, services, cash or for any other purpose since the
above date.
__ Never Received Card in the Mail: I requested a Check/ATM Card from NASA Federal, but never received the card in
the mail.
__ Unauthorized Use of Card Number: I had my Check/ATM Card in my possession when my account number was
fraudulently used.
I have not used this Visa Check/ATM Card number for any of the transaction(s) that I have listed on this form. I have not authorized anyone else,
orally or in writing, nor have I given consent nor do I have knowledge of implied consent, to use or have possession of said Visa Check/ATM Card
number. I have not received, and will not receive goods, services, or otherwise benefit, directly or indirectly, from transaction(s) made after the
date shown above.
Rev 07/14
VDPS Fraudulent Dispute Form

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I believe that sales drafts, ATM transaction(s), telephone/mail orders, or applications bearing my purported signature, or the purported signature
of person(s) authorized to use my Visa Check/ATM Card number following the date reported above, are and will be forgeries.
By signing below I certify to the best of my knowledge and belief, that all of the information on this form is true, correct, complete, and made in
good faith. I also understand that this form may be provided to federal, state, and local law enforcement agencies for such action with their
jurisdiction as they deem appropriate. I understand that knowingly making any false or fraudulent statement or representation on or with this form
may constitute an imposition of a fine, imprisonment or both.
Signed _____________________________________
Cardholder Signature
Date: ______________
*Participating Instant Issue branches; Annapolis, Collington, Bowie, Greenbelt, Columbia, Rockville, Headquarters, Falls Church, and Oak Hall
In Branch Use Only
Acknowledge by NASA FCU Branch: Teller ID and Signature: Date:
Rev 07/14
VDPS Fraudulent Dispute Form

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FRAUDULENT TRANSACTION DISPUTE FORM
Name: ________________________________________________ Visa card number:___________________________________
I certify that my Visa card was:
Lost (0) Stolen (1) Card not received (2) Counterfeit, card present (4) Card is still in my possession (6)
The following transaction(s) were not made by me or anyone authorized to use my Visa card.
1. Date: _______________ Amount: _____________________ Merchant: _________________________________________
2. Date: _______________ Amount: _____________________ Merchant: _________________________________________
3. Date: _______________ Amount: _____________________ Merchant: _________________________________________
4. Date: _______________ Amount: _____________________ Merchant: _________________________________________
5. Date: _______________ Amount: _____________________ Merchant: _________________________________________
6. Date: _______________ Amount: _____________________ Merchant: _________________________________________
7. Date: _______________ Amount: _____________________ Merchant: _________________________________________
8. Date: _______________ Amount: _____________________ Merchant: _________________________________________
9. Date: _______________ Amount: _____________________ Merchant: _________________________________________
10. Date: _______________ Amount: ____________________ Merchant: _________________________________________.
In the event additional charges are identified subsequent to the completion of this affirmation, I authorize my credit union to add those
subsequent transaction(s) to this affirmation.
I certify that I did not use and that I did not authorize anyone else to use my card for the Disputed Transaction(s) identified above. I also certify
that I did not receive and value or benefit in connection with the Disputed Transaction(s). I have made available above all information and
suspicions I have about the Disputed Transaction(s). I authorize you to share the above information with law enforcement, banking regulators
and other third parties in connection with any investigation of the Disputed Transaction(s), including any criminal investigation. I agree to
cooperate in any such investigation and in the prosecution of any person believed to be responsible for fraudulently using my card.
I certify that the information in the Fraudulent Transaction Dispute Form is true and correct.
________________________________________________
Cardholder Signature
________________________
Date
Credit Union Use Only:
Required certification:
We certify that our cardholder neither participated in nor authorized the referenced transaction(s).
Issuer certifies account was closed ___/___/___
Issuer certifies fraud was reported on DPS VROL ___/___/___
Issuer certifies account was placed on the Exception File, with a pickup code on ___/___/___
If Applicable:
Issuer certifies dispute was received via their Online Secure Banking Environment (if applicable) and that unique identity
represents the cardholder’s signature.
Rev 07/14
VDPS Fraudulent Dispute Form