Debit Card Transaction Dispute

Personal Information

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

The charges are disputed because
- Customer did not 1- participate in nor authorize this/these transaction(s); 2- authorize anyone else to make this/these transaction(s); or 3- receive any goods or services as a result of this/these charge(s).
- Customer’s account was billed twice for the same transaction.
- Customer requested an amount and was charged the amount for an ATM transaction however did not receive that amount
OK The charges are disputed because is required
Posting dates of duplicate transactions (if applicable)
Optional OK Posting dates of duplicate transactions (if applicable) is required
Amount received from incorrect ATM transaction (if applicable)
Optional OK Amount received from incorrect ATM transaction (if applicable) is required

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

Notes
Optional OK Notes is required
- 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.
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
- By selecting this box I acknowledge that I am not under the age of 13 and approve submission of this information.
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