Fee Refund Request Form

This form is not to be used to report Fraud. If you believe you have had unauthorized or

fraudulent transactions on your account, please call the credit union at (605) 342-7776 at your

earliest convenience.

We want to move quickly to protect your account.

This form is to provide a means to explain why you believe the credit union has unfairly or

mistakenly charged a fee for services provided.

Please complete the form and mail it to:

MED5 Federal Credit Union

ATTN: Operations

625 Flormann St.

Rapid City, SD 57701

We will review your request and determine if a refund is appropriate given your circumstances.

If a refund is granted, we will credit your account and send you a receipt in the mail.

Please complete the form below

Name *
Acknowledgement *