Fillable Written Statement Of Unauthorized Use Of Access Device Form printable pdf download

Written Statement Of Unauthorized Use Of Access Device Form

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WRITTEN STATEMENT OF UNAUTHORIZED USE OF ACCESS DEVICE

Name: __________________________________________________________________________

Account Number: _______________________

Card Number: _________________________

I, ______________________ hereby attest that:

I have carefully examined my checking/savings statement(s) for the period(s) ___________ and that the following

transactions were not made by me or anyone authorized by me.

Transaction Date

Amount

Transaction Type

ATM/POS Location

(Please attach additional transaction information if needed)

Check all applicable boxes:

I certify that I had possession of the ATM card indicated above at the time the described transaction took place.

I certify that I gave the ATM card indicated above to ________________on _________, whose address is

___________________________________________________________________.

I certify that I had possession of my Personal Identification Number (“PIN”) at the time the described transaction

took place.

Please complete all requested information.

Was the PIN accessible to the unauthorized user? _________________________________________

Was the PIN written on the card? _____________________________________________________

Was the PIN written on anything else? _________________________________________________

I first learned that the ATM/Debit Card was lost/stolen on _____________________. The loss/theft was reported to the

Commonwealth Business Bank on ______________________________ at its _________________________________.

The circumstances of the loss/theft are as follows:

______________________________________________________________________________________________

I suspect the EFT transaction(s) described is an error for the reasons indicated above. By signing below, I agree to accept

the results of this investigation and the accountability for the full amount disputed if no error is found.

I DECLARE UNDER PENALTY OF PERJURY, ACCORDING TO THE LAWS OF THE STATE WHERE THIS AFFIDAVIT IS EXECUTED AND

THE LAWS OF THE STATE IN WHICH MY ACCOUNT IS MAINTAINED THAT I HAVE READ THE FOREGOING AND THAT THE

FOREGOING IS TRUE AND CORRECT

__________________________

_________________________________

Date

Signature

[Revised 2.2013]

Written Statement Of Unauthorized Use Of Access Device Form

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