Instant Pay Dispute Form

Form Instructions

Please complete, print, sign, date and mail this application to:

Star One Credit Union
Attn: Support Services
P.O. Box 3643
Sunnyvale CA 94088-3643

Date

First name

Last name

Contact Phone Number

Date of First Unauthorized Transaction

Amount of First Unauthorized Transaction

Date of Second Unauthorized Transaction

Amount of Second Unauthorized Transaction

Date of Third Unauthorized Transaction

Amount of Third Unauthorized Transaction

Date of Fourth Unauthorized Transaction

Amount of Fourth Unauthorized Transaction

Use the back of the form to list additional unauthorized transactions.

Do you know the person who performed the transactions?

Yes No

What is the nature of the payment?

Have you transacted with the recipients in the past?

Did you attempt to resolve the issue with the person who performed the transactions?

Yes No

What was the response to your attempt to resolve?

Did you feel you were scammed?

Yes No

Explanation of events that led to unauthorized transaction(s)

By signing below, you certify the following:

You did not perform the transactions identified above, and did not receive any personal benefit from the transactions. The transactions were not performed by anyone that you authorized.
You do not know who performed these transactions, or if you do know, you have provided this information to the Credit Union.
You understand that the Credit Union may provide this information to law enforcement authorities in order to investigate and prosecute persons involved in the unauthorized transactions. You agree to cooperate with such investigation. You certify that the information you have provided on this form is true and accurate to the best of your knowledge.

___________________________________________

Member Signature

_______________________

Date