Atm Withdrawal Dispute Form printable pdf download

Atm Withdrawal Dispute Form

ATM withdrawal dispute form

Section 1

Debit / ATM Card

Cardholder

Number

Address

Member Number

Disputed

Cardholder Name

Amount

Cardholder Phone

Numbers

Posting Date

Transaction

Merchant Name

Date

Merchant Location

Cardholder Signature

Section 2

Reasons - Please select one (Receipt must be attached for all ATM disputes)

I acknowledge participation in the ATM transaction, but I did not

receive any funds.

I acknowledge participation in the ATM transaction, but received only

a portion of my funds.

I requested $ _____________; I received $_______________

I acknowledge participation in that ATM transaction, but it was twice.

I did not authorize the above transaction, however the card was in

possession

At the time of the transaction, the card was LOST. Date the card was

lost:_________________ Date the card was reported

lost:__________________

At the time of the transaction, the card was STOLEN. Date the card

was stolen:_________________ Date the card was reported

stolen:__________________

**ATM disputes can not be processed until FIVE business days from posting date.

Atm Withdrawal Dispute Form