Fillable Atm Deposit Dispute Form printable pdf download

Atm Deposit Dispute Form

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ATM Deposit Dispute Form

Return this form and any supporting documents so your dispute can be processed in a timely manner.

Cardholder Name:_________________________

Account Number: _________________________

Card Number: ____________________________

Total Deposit Amount: $____________________

Transaction Date: __________________________

Dispute Amount: $_________________________

I did not receive credit for an attempted deposit at a UFCU ATM.

UFCU ATM #: ___________________

Address: ___________________________________________________________

Choose from one of the dispute categories below:

Please check the appropriate box below that matches your dispute type the closest.

Deposit Type:

Check (please list the amount of each check)

$______________ $______________ $______________ $______________ $______________

$______________ $______________

Cash (please specify the denominations)

$100 x ______________ $50 x ______________ $20 x ______________ $10 x ______________

$5 x ______________ $1 x ______________

Detailed Explanation:

_________________________________________________________________________________________________

I swear this Cardholder Dispute Form is true and understand that making a false sworn statement is subject to Federal and/or State

statutes and may be punishable by fines and/or imprisonment.

I give my consent to have this dispute/claim reviewed by a credit union investigator and understand that I may be asked to provide

additional details for this investigation.

I also understand that incomplete or inaccurate information could result in the decline of my dispute

____________________________________________________________________

_____________________________

Cardholder Signature (Required)

Date

Credit Union Use Only:



If the amount being disputed exceeds $1,000 please request management approval before issuing provisional credit



SD SC GL is the required Transaction Codes for issuing provisional credit in Episys



Please use the ATMDeposit.0 (725030-0000.0000) GL when issuing provisional credit



The Shared Comment should read as such: Prov cr ATM# 457*** Deposit Dispute

Submitted By: _______________________________________________

Atm Deposit Dispute Form

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