Personal Information

  • OK Cardholder Name is required
  • OK Last 4 Digits of ATM/Debit Card is required
  • OK Account Number is required
  • OK Phone is required
  • Optional OK Secondary Phone is required
  • OK E-mail is required

Disputed Transaction Information

  • OK Merchant is required
  • OK Transaction Date is required
  • OK Transaction Amount is required
  • Optional OK Merchant (2) is required
  • Optional OK Transaction Date (2) is required
  • Optional OK Transaction Amount (2) is required
  • Optional OK Merchant (3) is required
  • Optional OK Transaction Date (3) is required
  • Optional OK Transaction Amount (3) is required
  • Optional OK Merchant (4) is required
  • Optional OK Transaction Date (4) is required
  • Optional OK Transaction Amount (4) is required
  • Optional OK Merchant (5) is required
  • Optional OK Transaction Date (5) is required
  • Optional OK Transaction Amount (5) is required

Reason for Dispute

  • The charges are disputed because

    OK The charges are disputed because is required
  • Optional OK Posting dates of duplicate transactions (if applicable) is required
  • Optional OK Amount received from incorrect ATM transaction (if applicable) is required

General Questions

  • OK Are you curently in possession of your ATM/Debit Card? is required
  • OK When did you discover your card was lost or stolen? is required
  • OK Indicate whether the card has been lost, or, if stolen, if the theft has been reported and to whom is required
  • OK Have you ever authorized anyone to use your Debit/ATM Card? is required
  • OK Whom did you authorize? is required
  • OK Do you suspect someone may have used your card? is required
  • OK Where is your secret code kept? is required
  • OK What date did you notify us of the fraud or error? is required

Notes

  • Optional OK Notes is required
    OK If you provide your contact information you authorize Fidelity Bank or its affiliates to contact you. Your authorization allows us to use text messaging and automatic telephone dialing systems in connection with calls made to any telephone number you provide, even if the telephone number is assigned to a cellular or mobile telephone service or other service for which the called party is charged. You may contact us anytime to change these preferences. is required
    OK By selecting this box I acknowledge that I am not under the age of 13 and approve submission of this information. is required
  • OK is required