NOTIFICATION OF DISPUTED TRANSACTION

If a transaction appears on your statement that you believe is an error, and you have been unable to resolve The situation with the merchant, please complete and sign a copy of this form using blue or black ink. This Form must be received at the Card Services address stated on your statement or at the bottom of this form Within 60 days of the closing date as printed on your statement. Please include a copy of your statement Highlighting the disputed transaction when mailing this form to Card Services.

Cardholder Information (required – Please Print)

Cardholder Name: ___________________________________________________________________

Cardholder Address: _________________________________________________________________

Home Phone (___) ______________________ Work Phone* (____) ____________________________

Card Used (16 digits): ___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___-___ ___ ___ ___

Transaction Amount: $______________________ Transaction* Date_____________________________

Disputed Amount: $_____________________ Reference* #: ___________________________________

Merchant Name:_____________________________________________________________________

**(Required) I contacted the merchant on ____/____/____ (date) in an attempt to resolve this dispute.

The merchant’s response was*: ___________________________________________________________

__________________________________________________________________________________.

Signature*___________________________________________ Date*: _________________________

____ I certify that the charge listed above was not made by me or a person authorized by me to use my card.In addition, neither I, nor anyone authorized by me received the goods or services represented by this charge.

____ I do not recognize the above transaction. Please provide me more information.

___ Although I did participate in a transaction with the merchant, I was billed for ______transaction(s) totaling $_____________ that I did not participate in, nor did anyone else authorized to use my card. I do have all my cards in my possession. Enclosed is a copy of my sales slip for the valid charge.

___ I have not received the merchandise that was to have been shipped to me. Expected date of delivery was ___________(mm-dd-yy). I contacted the merchant on __________(mm-dd-yy) and the merchant’s response

was________________________________________________________________________________

___________________________________________________________________________________. (In order to assist you more effectively you must contact the merchant and inform us of their response.)

___ I have returned the merchandise on ________________(mm-dd-yy) because

___________________________________________________________________________________.
(Please provide a copy of the return receipt, or proof of return.)

CHOICE ONE COMMUNITY CU, 101 Hazle St., Wilkes-Barre, PA 18703