ATM Error Report

Customer Information

  • OKFirst Name is required
  • OKMiddle Initial is required
  • OKLast Name is required
  • Social Security Number

    OKSocial Security Number is required
  • Date of Birth

    OKDate of Birth is required
  • OKEmail is required
  • OptionalOKMother's Maiden Name is required

Address Information

  • OKStreet is required
  • OKCity is required
  • OKState is required
  • OKZip is required
  • Cell/Home Phone

    OKCell/Home Phone is required
  • Work Phone

    OKWork Phone is required

Card Information

  • OKCard Number is required
  • OKAccount Number is required

Loss Information

  • Please Select One

    OKPlease Select One is required
  • OKAmount Requested is required
  • OKAmount Received is required
  • Date of Transaction

    OKDate of Transaction is required
  • OKLocation of ATM is required
  • OptionalOKError/Screen Message Displayed is required
  • OptionalOKAdditional 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.

  • OKSignature is required
  • OKMother's Maiden name or Account Code is required
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