VISA Debit Card Fraudulent Dispute Transaction Form

Please use this form for fraudulent transactions only. It must be completed no later than 60 days after we send you the first statement on which the fraudulent transaction appears. Disputes received on transactions after 60 days cannot be processed.

  • I am completing the Cardholder Dispute form for the purpose of establishing the fraudulent use of my Debit/ATM card(s).
  • I did not give, sell, or trade my card(s) to anyone nor did I give anyone permission to use my card(s).
  • I have no knowledge that my spouse or minor child(ren) made any transaction(s) on or after the date of the first fraudulent transaction(s).
  • I did not receive any benefit from the unauthorized use of my Debit/ATM card(s).
  • I did not use my card nor authorize the use of my card by anyone else after I discovered the unauthorized use of my card.
  • I have examined all of the unauthorized transactions and in each instance I did not originate the transaction nor authorize it.
  • Further, I did not receive proceeds or benefits from any of these transactions.
  • I give my consent to have this dispute/claim reviewed by a Lake Sunapee Bank, a division of Bar Harbor Bank & Trust, investigator and understand that I may be asked to provide additional details for this investigation.
  • I understand that incomplete or inaccurate information or failure to provide additional details could impact the outcome of the dispute.
  • You must call 800-281-5772 to cancel your card to prevent further fraudulent transactions.

Customer Information
Fraudulent Transaction Information

The following transactions were not made by me or anyone authorized to use my Visa card:

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