ATM / DEBIT CARD DISPUTE FORM

Name:

Account Number:

Card Number:

Card in possession: Yes OR No

If no, was it: Lost OR Stolen

Date card was lost or stolen:

Date reported:

Please select what type of dispute fits your situation best:

I did not authorize the charge / charges. – I confirm that I did not authorize or participate in the transaction(s) in any way, nor did I authorize anyone else to use my card.

I was billed twice by the same merchant or was mischarged by a merchant, and I certify one transaction is valid but posted more than once or that the merchant charged me an incorrect amount.

Valid transaction amount:	Date posted:
Incorrect Transaction amount:	Date posted:

I returned merchandise but no credit was given. (You must have attempted to return the merchandise.) Please give as many details as you can in the ADDITIONAL COMMENTS SECTION.

I did not receive the service / merchandise. Please use the ADDITIONAL COMMENTS SECTION to describe the situation and merchant’s response. incorrect amount.

ATM – No cash was received.

Amount requested:

Date:

ATM – Partial cash – Cash was dispensed at ATM but not for correct amount.

Amount requested:

Amount received:

Date:

OTHER – Please provide a detailed description in the ADDITIONAL COMMENTS SECTION.

Date	Merchant Name / ATM Location	Dollar Amount

ADDITIONAL COMMENTS SECTION:

I certify that the charge(s) above were not made by me or by a person authorized by me to use my card, nor were the goods or services represented by the above transaction received by myself or by a person authorized by me.

CARDHOLDER SIGNATURE:________________________________ DATE:_______/_______/_______

RECEIVING EMPLOYEE SIGNATURE:_______________________________________

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