Cardholder Information Cardholder Name Home Phone ()-First three digitsSecond three digitsLast four digits Work Phone ()-First three digitsSecond three digitsLast four digits Cell Phone ()-First three digitsSecond three digitsLast four digits Mailing Address City State Zip Email Address Card Number Atomic Account Number Transaction Date Date and timeCalendarToday Transaction Amount Merchant Name Did the cardholder sign up for a free trial or agree to just pay for shipping? If cardholder received anything fromthe merchant, cardholder must provide proof of return or cancellation number. Credit Not Received I did not receive credit from the merchant. What was purchased? Expected date of credit from Merchant Date and timeCalendarToday Date merchandise or service was received Date and timeCalendarToday Date merchandise returned to merchant or service was cancelled Date and timeCalendarToday Return authorization or cancellation number, if available Tracking number for returned merchandise Please provide copy of return receipt or proof of return Upload file Please describe your reason for cancellation or return Paid by Other Means I paid for transaction via another payment method but Atomic Debit Card was billed also. What was purchased? Date of purchase Date and timeCalendarToday I paid with a CheckCashAnother CardOther Please provide copy of your receipt, the front and back of the cleared check or copy of the card statement showing payment Upload file Cancelled I cancelled service with merchant but continue to be billed. What was purchased Were you advised of the merchant cancellation policy? What was your method of cancellation PhoneMailEmailOther Date of cancellation Date and timeCalendarToday Who did you speak with to cancel? Cancellation number provided by merchant Please provide copy of correspondence (email, letter, phone bill etc) in your attempt to resolve with merchant. Upload file Incorrect Amount/Duplicate Processing I was billed the wrong amount or the amount posted to the account more than once. INCORRECT AMOUNT: I should have been billed $ Please provide receipt. Upload file INCORRECT AMOUNT: What was purchased? DUPLICATE PROCESSING: Amount of duplicate posting $ DUPLICATE PROCESSING: Date of original posting Date and timeCalendarToday DUPLICATE PROCESSING: Date of duplicate posting Date and timeCalendarToday DUPLICATE PROCESSING: What was purchased? Merchandise/Service Not as Described I received merchandise that was damaged, defective, not what I ordered; the service I received was not what I expected based upon Merchant description. What was purchased? Date merchandise/service received Date and timeCalendarToday What was the issue with the merchandise/service? Date you returned merchandise or cancelled service Date and timeCalendarToday Return/cancellation authorization number given by merchant Tracking number for returned merchandise Non-Receipt of Merchandise or Service I did not receive what I ordered by the agreed upon date. What was purchased? Date you expected to receive merchandise or service Date and timeCalendarToday Was merchandise to be shipped or picked up? What address was merchandise to be shipped to? Dispute Reason Not Previously Covered. Please describe the dispute reason Please provide a full description of your interaction with the merchant in your attempt to resolve the issue? Date Date and timeCalendarToday Merchant Response Member Acknowledgement I have completed this affidavit for the purpose of establishing the unauthorized use of my Atomic ATM and/or Debit Card. I affirm that I did not give, sell or trade my card to anyone, nor did I give Atomic Credit Union authority to release any information regarding my card, account and/or transaction details to be used to investigate and/or prosecute any person(s) who may be responsible for fraud. This includes, but is not limited to, the release to any party associated with transactions or any Federal, state, or local law enforcement agencies. By typing my name below I acknowledge that I have read the above statement and agree that it is true. Cardholder Signature Type your name in the box in lieu of a physical signature.