Unauthorized Electronic Transaction

Complete one form for each unauthorized transaction. You have 60 days from receiving your account statement to notify us of an unauthorized electronic transaction on your account. Even if you tell us orally about an unauthorized transaction, you must submit a written or electronic form to confirm your claim. Once submitted, the Bank will investigate your claim within 10 business days, or provisionally credit your account the amount in dispute. Within 45 days, we will conclude our investigation and either:

1. notify you your provisional credit is final OR
2. reverse the provisional credit if we deny the claim

Customer Information

• First Name
  OK First Name is required
• Middle Initial
  OK Middle Initial is required
• Last Name
  OK Last Name is required
• Social Security Number
  OK Social Security Number is required
• Date of Birth
  OK Date of Birth is required
• Email
  OK Email is required
• Mother's Maiden Name
  Optional OK Mother's Maiden Name is required

Address Information

• Street
  OK Street is required
• City
  OK City is required
• State AK - AlaskaAL - AlabamaAR - ArkansasAZ - ArizonaCA - CaliforniaCO - ColoradoCT - ConnecticutDC - District of ColumbiaDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiIA - IowaID - IdahoIL - IllinoisIN - IndianaKS - KansasKY - KentuckyLA - LouisianaMA - MassachusettsMD - MarylandME - MaineMI - MichiganMN - MinnesotaMO - MissouriMS - MississippiMT - MontanaNC - North CarolinaND - North DakotaNE - NebraskaNH - New HampshireNJ - New JerseyNM - New MexicoNV - NevadaNY - New YorkOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVA - VirginiaVT - VermontWA - WashingtonWI - WisconsinWV - West VirginiaWY - Wyoming
  OK State is required
• Zip
  OK Zip is required
• Cell/Home Phone
  OK Cell/Home Phone is required
• Work Phone
  OK Work Phone is required

Account Information

• Account Number
  OK Account Number is required

Type of Electronic Transaction

• Please Select One

  • Debit or ATM Card
  • Auto-withdrawal from your account via ACH (not using a Debit or ATM card)
  • Auto deposit
  OK Please Select One is required

• Last 4 Digits of Card Number
  OK Last 4 Digits of Card Number is required

Please be aware, reporting an unauthorized card transaction will cause your current card to be immediately disabled. A new card should be ordered through the Debit / ATM Card Application form.

• Have you lost your card?

  • Yes
  • No
  OK Have you lost your card? is required

• Date you noticed your card was missing
  OK Date you noticed your card was missing is required

Please be aware, many of these types of transactions are because of auto payments that customers have with merchants, like a gym membership. We will refute this transaction on your behalf, but if the merchant can prove there is a payment agreement with you, the claim will be denied. If you do not who this merchant is, we may have to close this account and open a new one to protect you from such transactions in the future.

We will return this deposit to the processor.

Type of Dispute

• Please select one

  • I have examined all of the unauthorized transactions and in each instance I did not originate the transaction nor authorize it. Furthermore, I did not receive any of the proceeds or benefits of any such item(s).
  • I did authorize the transaction, but it is different than the amount authorized
  • I did authorize this transaction and amount, but the goods were not received
  • I did authorize this transaction and amount, but the goods were different than advertised
  • I did authorize this company to make a transaction, but have since revoked it
  • Unauthorized ATM withdrawal
  OK Please select one is required

• Amount authorized
  OK Amount authorized is required
• Comments
  Optional OK Comments is required

Please be aware this transaction is not unauthorized, but a civil matter between you and the merchant. You have protections under the MasterCard brand from such purchases and we will place the claim on your behalf, but no conditional credit of the amount in dispute will be given.

• When was the order placed?
  OK When was the order placed? is required
• Comments
  Optional OK Comments is required

Please be aware this transaction is not unauthorized, but a civil matter between you and the merchant. You have protections under the MasterCard brand from such purchases and we will place the claim on your behalf, but no conditional credit of the amount in dispute will be given.

• When was the order placed?
  OK When was the order placed? is required
• How were the goods different than expected?
  OK How were the goods different than expected? is required

• When was the order placed?
  OK When was the order placed? is required
• Why did you revoke the order?
  OK Why did you revoke the order? is required

• Do you still have your card?

  • Yes
  • No
  OK Do you still have your card? is required

• Did you give your card and PIN to another person to use on your behalf?

  • Yes
  • No
  OK Did you give your card and PIN to another person to use on your behalf? is required
• Amount authorized
  OK Amount authorized is required

• Do you know the name of this person?

  • Yes
  • No
  OK Do you know the name of this person? is required
• Name of Person
  OK Name of Person is required
• Address of Person
  Optional OK Address of Person is required
• City
  Optional OK City is required
• State AK - AlaskaAL - AlabamaAR - ArkansasAZ - ArizonaCA - CaliforniaCO - ColoradoCT - ConnecticutDC - District of ColumbiaDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiIA - IowaID - IdahoIL - IllinoisIN - IndianaKS - KansasKY - KentuckyLA - LouisianaMA - MassachusettsMD - MarylandME - MaineMI - MichiganMN - MinnesotaMO - MissouriMS - MississippiMT - MontanaNC - North CarolinaND - North DakotaNE - NebraskaNH - New HampshireNJ - New JerseyNM - New MexicoNV - NevadaNY - New YorkOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVA - VirginiaVT - VermontWA - WashingtonWI - WisconsinWV - West VirginiaWY - Wyoming
  Optional OK State is required
• Zip
  Optional OK Zip is required
• Phone of Person
  Optional OK Phone of Person is required
• Relationship
  Optional OK Relationship is required

• Will you prosecute this person?

  • Yes
  • No
  OK Will you prosecute this person? is required

• Have you filed a police report?

  • Yes
  • No
  OK Have you filed a police report? is required

Description of Transaction

• Date of Transaction
  OK Date of Transaction is required
• Merchant Name
  OK Merchant Name is required
• Dollar Amount
  OK Dollar Amount is required

• Additional Comments
  Optional OK Additional Comments is required

• Type your name here as your signature
  OK Signature is required
• Mother's Maiden name or Account Code
  OK Mother's Maiden name or Account Code is required

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