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    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

  • OK First Name is required
  • OK Middle Initial is required
  • OK Last Name is required
  • OK Social Security Number is required
  • Date of Birth

    OK Date of Birth is required
  • OK Email is required
  • Optional OK Mother's Maiden Name is required

Address Information

  • OK Street is required
  • OK City is required
  • OK State is required
  • OK Zip is required
  • OK Cell/Home Phone is required
  • OK Work Phone is required

Account Information

  • OK Account Number is required

Type of Electronic Transaction

  • Please Select One

    OK Please Select One is required

 

  • 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?

    OK Have you lost your card? is required
  • Date you noticed your card was missing

    OK Specify a date

 

    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

    OK Please select one is required

 

  • OK Amount authorized is required
  • 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.

  • OK When was the order placed? is required
  • 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.

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

 

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

 

  • Do you still have your card?

    OK Do you still have your card? is required
  • Did you give your card and PIN to another person to use on your behalf?

    OK Did you give your card and PIN to another person to use on your behalf? is required
  • OK Amount authorized is required
  • Do you know the name of this person?

    OK Do you know the name of this person? is required
  • OK Name of Person is required
  • Optional OK Address of Person is required
  • Optional OK City is required
  • Optional OK State is required
  • Optional OK Zip is required
  • Optional OK Phone of Person is required
  • Optional OK Relationship is required
  • Will you prosecute this person?

    OK Will you prosecute this person? is required
  • Have you filed a police report?

    OK Have you filed a police report? is required

Description of Transaction

  • Date of Transaction

    OK Date of Transaction is required
  • OK Merchant Name is required
  • OK Dollar Amount is required
  • Optional OK Additional Comments is required

Security Code

  • OK is required

    Please read this written statement carefully. You are cautioned that knowingly giving a false statement may subject you to criminal prosecution. You may be required to file a police report at your local police station and provide Washington Savings Bank a copy along with filing this written statement.

    I swear that this written statement is true and understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and or imprisonment. This written statement is true and correct.

  • OK Signature is required
  • OK Mother's Maiden name or Account Code is required
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