Error Resolution Request Form

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EFT - ERROR RESOLUTION REQUEST
Please fill out one form per transaction.
In the “Details” section, multiple boxes can and should be checked.
Today’s Date: ____________ Cardholder Name: _____________________________________
Cardholder’s Daytime Phone: __________________
Evening Phone: __________________
Address: _____________________________________________________________________
Account Type: _________________ Account Number: _________________________________
Debit Card Number: _____________________________ (# must match card used for purchase)
Details regarding the processing error or unauthorized transaction information as recorded below:
I did not authorize or participate in the following transaction(s).
The amount of the transaction below differs from the amount that I authorized at the
merchant or terminal location. I authorized $________________.
I do not recognize the transaction presented below.
I authorized one transaction in the amount of $____________________; however, this
amount has been deducted from my account _______ (#) times.
I authorized the following transaction; however, it was taken from the wrong account. It
should have been removed from account number _______________________________.
I did not receive the cash or merchandise represented by the transaction listed below.
I have my card in my possession.
I have reported my card lost/stolen. I reported this on __________________.
I have my receipt.
I do not have my receipt.
I have attempted to resolve this dispute with the merchant by: ___________________________
____________________________________________________________________________
Additional Comments or Information: _______________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Transaction Date: _________________ Transaction Time: ______________________________
Merchant/Terminal Name as it appears on statement: __________________________________
Amount in Question: $_____________ Authorized Amount: $____________________________
Cardholder Signature ____________________________________ Date___________________
Cardholder Signature ____________________________________ Date: __________________
Statement Taken By: ____________________________________ Date: ___________________
Branch Number: ______________________Dispute Filed: ______________________________
Dispute Resolved: ____________________ Cardholder Notified: _________________________

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