To begin, please fill out the fields in the form below. One of our representatives will contact you within one business day to complete the process.

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ATM Error Report

Customer Information

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

    - -
    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
  • Home Phone

    - -
    OK Home Phone is required
  • Work Phone

    - -
    OK Work Phone is required

Card Information

  • OK Card Number is required
  • OK Account Number is required

Loss Information

  • Please Select One

    OK Please Select One is required
  • OK Amount Requested is required
  • OK Amount Received is required
  • Date of Transaction

    OK Date of Transaction is required
  • OK Location of ATM is required
  • Optional OK Error/Screen Message Displayed is required
  • Optional OK Additional Comments is required

Security Code

  • OK is required

    Please read this affidavit carefully. You are cautioned that knowingly giving a false statement may subject you to criminal prosecution for perjury.

    I swear that this Dispute Affidavit 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. Under the pains and penalties of perjury, I so swear.

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