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Debit Card Transaction Dispute
Personal Information
Cardholder Name
OK
Cardholder Name is required
Last 4 Digits of ATM/Debit Card
OK
Last 4 Digits of ATM/Debit Card is required
Account Number
OK
Account Number is required
Phone
OK
Phone is required
Secondary Phone
Optional
OK
Secondary Phone is required
E-mail
OK
E-mail is required
Disputed Transaction 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
Reason for Dispute
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
General Questions
Are you curently in possession of your ATM/Debit Card?
No
Yes
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?
No
Yes
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
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
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