Uwharrie Bank
Debit Card Dispute Form

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Date: April 24, 2025
Cardholder's Name:
Card Number (16 digits):
Transaction Amount Transaction Date Merchant

Please tell us why you think the item(s) noted above is an error
(select only one).

  1. Although I did engage in the above transaction, I dispute the entire charge, or a portion of it, in the amount of $ .
  2. I certify that the transaction above was a single transaction but appears duplicated on my account. Sales #1 .
  3. I notified the merchant on (date) to cancel the preauthorized order (reservation). The cancellation #, the date & time of cancellation and the reason for cancellation are as follows:
  4. I have not received the requested merchandise that was shipped to me on (date).
  5. Merchandise was shipped to me and arrived to my dissatisfaction. I was dissatisfied because , and I returned it to the merchant on (date).
  6. I do not recognize the transaction(s) listed above and would like additional information about the transaction(s).
We may contact you to provide copies of all documentation that will help us investigate your dispute such as credit slips, sales tickets, contracts and invoices. Cardholder must provide written explanation of request on Page 2.
Cardholder Acknowledgement:
(select all that apply).
  1. I have contacted the merchant and requested that my account reflect the proper adjustment but have not received the adjustment.
  2. My card(s) and PIN(s) was (were) in my possession at the time of the transaction(s), and I have no further knowledge of the transaction(s).
  3. I certify that the charge(s) above was (were) not made by me or a person authorized to use my card nor were goods or services represented by the transaction(s) received by me or a person authorized by me.
Written Statement Under Penalty of Perjury
Explanation of Dispute (as written by the cardholder):
I certify under penalty of perjury that the foregoing is true and correct. I understand that by entering in my Username and Password used to access Uwharrie Bank's Online Banking is my electronic signature used to authenticate my request for any of the selected services. By clicking the Submit button below, I agree to abide by all terms, conditions, and disclosures pertaining to the services requested.
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