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VISA PURCHASING CARD CITY OF LARAMIE CARDHOLDER DISPUTE FORM CARDHOLDER BACKGROUND ACCOUNT NUMBER NAME ADDRESS PHONE EMAIL ADDRESS DISPUTE DETAILS AMOUNT OF DISPUTE PROVIDE NECESSARY DETAILS ABOUT THE DISPUTED ITEMS(S): MAIL OR FAX THIS FORM TO: UMB BANK CARD CENTER CARDHOLDER DISPUTES P.O. BOX 419734 KANSAS CITY, MO 64141 FAX: [PHONE REDACTED] DATE SIGNATURE