page 121 Complete all x00660069elds below select the option that best x00660069ts the nature of your dispute below sign and date the signature section ATTN Disputes PO Box 20541 Atlanta ID: 883050
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1 page 1/2 Form Instructions: 1 — Comp
page 1/2 Form Instructions: 1 — Complete all �elds below, select the option that best �ts the nature of your dispute below, sign and date the signature section. ATTN: Disputes, PO Box 20541 Atlanta, 30320-2541, Transaction Date Dispute Amount Total Transaction Amount A cardholder must �rst attempt to resolve a billing error or disputed transaction before the Credit Union can take action on your claim. I did authorize this transaction with the merchant, but I attempted to cancel it on A copy of the cancellation The amount of my transaction is different than the amount that appeared on my receipt. Please attach your sales voucher, Only one transaction was authorized. The charge is a duplicate charge or an additional charge of that was unauthorized. Please attach your sales voucher, order con�rmation or any documentation to validate the charge agreed I did authorize the transaction but I did not receive the merchandise or services. Fifteen days have passed since the expected Please provide proof that the merchan
2 t was noti�ed that merchandis
t was noti�ed that merchandise was not received or the I did authorize the transaction, but the merchandise or services received were defective or not as described as according to describing the difference between what was ordered and what was received, what was defective or why the purchase is Another method of payment was accepted for this transaction but my account was still charged. Please provide proof of the I received a credit on the above transaction but it has not appeared on my account. If you have a credit slip, voucher, or a refund I have a general dispute with a merchant that is not detailed in any option above. Please provide a detailed account of the nature of the dispute including, dates, communications, and any documentation to support your claim. P.O. Box 20541, Atlanta, GA 30320 Telephone: Toll-Free: Web: DeltaCommunityCU.com page 2/2 PLEASE NOTE THAT FAILURE TO PROVIDE ALL REQUESTED DOCUMENTATION COULD AFFECT THE OUTCOME OF YOUR CLAIM. Signature Date P.O. Box 20541, Atlanta, GA 30320 Telephone: Toll-Free: Web: DeltaCommunityCU.co