Debit Card Dispute

Individual Information

Cardholder Name Address E-mail 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 Disputed Amount $ Name & Location

Total Disputed Amount

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 have done only one transaction at the merchant, but I was charged the below amount of times

Number of times charged?

I did not receive merchandise on the expected date below. Please provide detailed description of merchandise/service

Date Detailed description of merchandise/service

Cash was not dispensed at the ATM, but I was charged for the entire amount. Cash was partially dispensed.

Cash was dispsened 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 Date

Call Us800-422-3372