CARDHOLDER DISPUTE FORM & AFFIDAVIT
For Fraudulent Use of a Credit Card, ATM, or Check Card
THIS FORM MUST BE NOTARIZED
 unless hand-delivered to the Credit Union and signed in the presence of a Star One employee
 
Complete, PRINT, sign and either mail, deliver, or fax this form, (after notarization or signing in presence of Star One employee), to Star One Credit Union. See instructions below. If you have any questions or concerns, call our Card Services department at (408) 543-5202 or toll free at (866) 543-5202.
 
Cardholder Name
Date
Member Number
Card Number
Best Contact Phone #
Phone # Type
Type of Card Loss : Lost Stolen Never Received
In my possession at all times when fraud occurred

Has this loss been reported to police department?
Yes No
Authority contacted
Phone

I have examined the charges made to my account and I am disputing the following charge(s) as neither I nor any person authorized by me to use my card, made the charge(s) listed below. In addition, neither I nor anyone authorized by me received goods and services represented by the transaction(s).
Transaction Information:
Merchant Name/Terminal Location
Amount
Posting Date
Amount Disputed
If additional space is needed, please list on separate sheet of paper, sign and attach.
 Total Claim $
Explain the circumstances surrounding fraud:


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. Further, I understand I may be required to comply with a court order or subpoena to give testimony. I swear this affidavit 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.

State of , County of . Subscribed and sworn to before me this day of 20 .
Proved to me on the basis of satisfactory evidence to be the person who appeared before me.

________________________________
Notary Public                 
 or _____________________________________
Star One Credit Union Authorized Signature

Cardholder's Signature X________________________________ Date____________
Notice: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, submits a statement of claim containing any false, incomplete or misleading information commits a crime.        


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Mail this completed form to:
Star One Credit Union
Attn: Card Services
PO Box 3643, Sunnyvale, CA, 94088-3643
Fax (408) 543-5203 Attn: Card Services