Cardholder Dispute Form | Northwest Federal Credit Union

Member Name

Last Four Card Number

Last Four NWFCU Account Number

Merchant Name

Transaction Amount $

Dispute Amount (if different) $

CARD RULES GOVERNING THESE DISPUTES REQUIRE THAT YOU ATTEMPT TO RESOLVE YOUR DISPUTE WITH THE MERCHANT BEFORE COMPLETING THIS FORM. YOU MUST INCLUDE THE EVIDENCE OF YOUR ATTEMPT AND A DETAILED ACCOUNT OF THE SITUATION AS TO WHY THE MERCHANT WAS UNWILLING OR UNABLE TO RESOLVE THE ISSUE.

Please check the appropriate box below that matches your dispute type the closest.

Return this form and any supporting documents so that your dispute can be processed in a timely manner. Please answer all appropriate questions below.

Dispute Type

Cancelled Transaction

Returned Merchandise

Duplicate Charge

I paid for these goods or services by other means

Non-receipt of goods or service

A credit transaction posted as a debit in error

Incorrect Transaction Amount

Quality of services or goods, defective merchandise or not as described

Date of Cancellation

Cancellation Number

Is this a recurring charge

Yes

Reason for cancellation

Spoke with for cancellation and response

Expected date of receipt of merchandise or service

Was a credit receipt provided

Yes

If yes, provide a copy of the receipt.

Copy of Receipt

One file only.
100 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Other Comment

Date Returned

Method of Return

Date Received by Merchant

If returned by shipping, provide name of shipping Company and tracking #

If you have a credit slip, please provide date of credit and receipt #

Returned Merchandise Receipt

If you attempted to return the merchandise and merchant refused to accept, please provide name of person you spoke with and stated reason for merchant’s refusal to issue credit

Date you contacted the merchant

Date of 1st charge

Amount of 1st charge $

Date of 2nd charge

Amount of 2nd charge $

Describe your attempt to resolve with the merchant and who you spoke with

Payment Types

Cash

Check

Other

credit/debit card

Describe your attempt to resolve with the merchant and who you spoke with