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Cardholder Dispute (Fraud)

For fraudulent use of a credit card, ATM, or debit card.

Form Instructions

To submit this form online, log into Online Banking and locate the form in the "Online Forms" drop-down menu.

Complete, print and sign this form, then mail, deliver, or fax it to:

Star One Credit Union
P.O. Box 3643
Sunnyvale CA 94088-3643
Attn: Card Services
Fax: (408) 543-5203

If you have any questions or concerns, call us and ask to speak with our Card Services Department.

Your Information

Cardholder Name:
Member Number:
Card Number used in transaction:
Primary Contact Phone:
Phone # Type:
Has this loss been reported to police department?
Card Status:
Never Received
In my possession at all times when fraud occurred
Authority contacted:
Were you contacted by our Risk Management Department?

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 Posting Date Amount Disputed
For additional disputed transactions please list below within the "Explain the circumstances surrounding fraud" area. 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.

By completing and signing this form, I acknowledge that I have given a correct and true disclosure of the transaction I am disputing. I realize that Star One Credit Union may call upon me to supply additional supporting documentation to strengthen my claim against the merchant. I realize that not providing all details or exact information related to my dispute may delay the dispute resolution process.

Member Signature

Mail this completed form to:
Star One Credit Union
Attn: Card Services
PO Box 3643
Sunnyvale, CA 94088-3643

Or fax to (408) 543-5203
Attn: Card Services


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