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Get NetSpend CH006

This form must to be completed and submitted to Netspend as soon as possible but no later than 60 days after the date of the transaction in dispute. Print Form Dispute Notification Form - Unauthorized Credit/Debit Transactions Please complete this Dispute Notification Form to initiate a dispute relating to any unauthorized credit or debit transactions on your card. A decision will be made regarding whether the funds in dispute will be credited to your card within 10 business days after our receipt of the completed Dispute Notification Form. Supporting documentation will assist in our determination. Please keep in mind that if your card was lost or stolen or was used without your consent you may be liable for any unauthorized use of your card. You will not be liable however for any unauthorized use that occurs after you have instructed us to block activity on your card. To instruct us to block activity on your card please note in the appropriate place below that your card was lost or stolen* We also recommend that you reset your PIN and file a police report. Cardholder Name Phone Number Address City State Zip Card or Account Number Claim Number Please provide information for each transaction you are disputing submit up to 5 on one form Disputed Amount Date of Transaction MM/DD/YY Time of Transaction include AM or PM Merchant s Name Have you contacted the merchant Circle One - If yes will they provide a refund Circle One - Date expected MM/DD/YY - Amount expected Yes/No Transactions Date card was noticed missing/lost/compromised MM/DD/YY Does anyone else have access to your PIN Yes No If yes please explain how Please sign and fax to 512-531-8770 Include a full copy of the police report and any other supporting documents i*e* receipts emails shipping or tracking information contracts cancellation information when submitting this form* Card Holder Signature Date CH0006. You will not be liable however for any unauthorized use that occurs after you have instructed us to block activity on your card. To instruct us to block activity on your card please note in the appropriate place below that your card was lost or stolen* We also recommend that you reset your PIN and file a police report. To instruct us to block activity on your card please note in the appropriate place below that your card was lost or stolen* We also recommend that you reset your PIN and file a police report. Cardholder Name Phone Number Address City State Zip Card or Account Number Claim Number Please provide information for each transaction you are disputing submit up to 5 on one form Disputed Amount Date of Transaction MM/DD/YY Time of Transaction include AM or PM Merchant s Name Have you contacted the merchant Circle One - If yes will they provide a refund Circle One - Date expected MM/DD/YY - Amount expected Yes/No Transactions Date card was noticed missing/lost/compromised MM/DD/YY Does anyone else have access to your PIN Yes No If yes please explain how Please sign and fax to 512-531-8770 Include a full copy of the police report and any other supporting documents i*e* receipts emails shipping or tracking information contracts cancellation information when submitting this form* Card Holder Signature Date CH0006. .

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