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Transaction Enquiry For the investigation of POS/Visa/Internet/ATM/BPay transactions A. Membership Details
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Cardholder's details
Title
Given Name(s)
Surname
Address
Membership Number
Card Number
X X X X X X B. POS Dispute - PIN used Date
Time
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Amount
Merchant name
Merchant location Details of Problem
C. ATM Dispute Details - PIN used
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ATM Fraud Card Stolen
ATM Cash withdrawal malfunction ATM Cash deposit malfunction
Card Compromised Card Lost
All ATM frauds must be reported to the police and card cancelled Police Report Number Police Station
Name of Police Offficer
Transaction Details Date
Date & Time Police Report was made
Time
Location
ATM / system owner
Amount Requested
Amount Received
$
$
Details of problem
I agree to pay the ATM Dispute fee of $25.00 per transaction if any of the disputed transactions prove to be valid
D. Visa Transaction Dispute Details - PIN not used Card Lost
Card Stolen
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Card compromised
All card present visa transactions (paywave) must be reported to the police and card cancelled Police Report Number
Police Station
Name of Police Offficer
Date & Time Police Report was made
Reason for dispute I did not authorise the transaction(s) nor did any other party on the account I only authorised one of the transactions (apparent duplication) I acknowledge the transaction(s) occurred. However the amount on my statement is incorrect. Correct amount $
Sydney Credit Union Limited ABN 93 087 650 726 AFSL 236 476
TE/C-RA-1117
I did engage in the transaction but did not receive the goods/services ordered (e.g. mail/telephone order) I cancelled the authority with the merchant on the following date / / A copy of the cancellation letter to the merchant must be provided A refund receipt was issued but credit has not been received Details of Disputed Transaction(s)
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Please list disputed transactions individually below Date
Merchant Name
Amount (Aust $)
Amount (Foreign $)
$
$
$
$
$
$
I agree to pay the VISA investigation fee of $30.00 per transaction if any of the disputed transactions prove to be valid Additional information
E. Direct Entry Dispute Details
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I acknowledge the transaction was authorised. However the BSB or Account details are incorrect. I am seeking a return of funds. Note: It may not always be possible to recover a payment paid to an unintended recipient. Transaction Date Incorrect BSB No. Incorrect Account No. Incorrect Account Name details Amount
Correct BSB No.
Correct Account No.
Correct Account Name
I acknowledge the transaction was authorised. However the intended recipient is claiming funds have not been received. I am seeking a trace on this transaction. Transaction BSB Account Number Account Name Date Amount details I agree to pay the dispute fee of $25.00
F. BPay Details for Investigation
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Biller Name
Biller Code
Date Payment Due
Customer Reference Number
Receipt Number
Amount
$ Payment not received by Biller Payment made to wrong Biller Payment made with wrong Customer Reference Number Incorrect CRN
Payment duplicated
Correct CRN
Other (please provide details) I agree to pay the BPay dispute fee of $22.00 Bpay investigations are to be sent to the Finance Department.
Declaration I declare that the above information is true and correct. Signature
Signature
Date
X
/
/
X
Date
/
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Remote Access Use Only Operator Name
Sydney Credit Union Limited ABN 93 087 650 726 AFSL 236 476
Date and time received
TE/C-RA-1117