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Debit Card Dispute

Individual Information

Cardholder Name*
Address*
Email Address*
Phone Number*
16 Digit Card Number*
Account Number*
I am disputing the following transactions(s) for the reason given below.

Details of Disputed Items

If you have additional transactions please call 1.800.422.3372.
Date*
Month - Day - Year
Disputed Amount $*
Name & Location
Date
Month - Day - Year
Disputed Amount $
Name & Location
Date
Month - Day - Year
Disputed Amount $
Name & Location
Date
Month - Day - Year
Disputed Amount $
Name & Location
Currency
Total Disputed Amount $: {Currency}
At the time of the transaction(s), were you in possession of your card?*

Yes
No
Please select the most appropriate ONE

Unauthorized/Fraudulent
Duplicate/Multiple charges
Merchandise or service not received
ATM Dispute
I did not authorize this transaction/these transactions.

I did not authorize this transaction/these transactions.
I have done only one transaction at the merchant, but I was charged the below amount of times
I did not receive merchandise on the expected date below. Please provide detailed description of merchandise/service
Date*
Month - Day - Year
Detailed description of merchandise/service
Cash Details:

Cash was not dispensed at the ATM, but I was charged for the entire amount.
Cash was partially dispensed.
Cash was dispensed for the amount of $
ATM Charged me for $
Additional Information
Acknowledgement

I declare that the above information is true and correct to my knowledge. I understand that I can be held liable for all charges incurred if dispute raised by me is found invalid during the investigation. First Federal Savings Bank may contact me whenever it requires any further information.
Signature*
Today's Date*
Month - Day - Year
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Debit Card Dispute

Individual Information

I am disputing the following transactions(s) for the reason given below.

Details of Disputed Items

Acknowledgement