Visa Credit Card Dispute Form

Please contact the credit union within 120 days of the date of transaction to dispute the charges appearing on your monthly statement. 

This form can be faxed to 316-263-5757, or mailed to: TECU Credit Union, 6300 W. 21^st Street North, Wichita, KS 67205.

Cardholder’s Name ____________________________________

Account Number ______________________________________

Transaction Amount _______________________

Purchase Date ___________________________ 

Merchant Name _________________________________________

Explanation of why you are disputing the charge(s):

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What steps have been taken to resolve the dispute with the merchant (only if the cardholder participated in the transaction)

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Please include copies of any pertinent documentation to help prove cardholder’s case (receipts, brochures, proof of return, etc.)

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Cardholder Signature (on unauthorized transactions)