Member FDIC - Equal Housing Lender

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Unauthorized Debit Card Activity Form
Submitter Information (Required)
First Name
Last Name
File Upload Form. Follow these instructions to upload files.

  1. Click to select a file for upload. For large files, this process may take a couple of minutes.

  2. If you accidentally select the wrong file, click the red "DELETE FILE" next to its name to remove it.

  3. Your files will be attached to this form when submitting.

  4. Allowed File Types: JPG, JPEG, GIF, PDF, PNG, SVG, TIF, TIFF, TXT, Office Docs (Word, Excel, PowerPoint).
  5. IF YOU ARE UPLOADING FROM A MOBILE BROWSER, please select an existing file on your device, rather than attempting to upload files directly from the Camera app.

Resolve the errors marked in red before submitting again.
Contact Information
Phone Number:Email Address:

Mailing Address

We will not update our records with this information. If this information needs updated, please submit an "address/contact change form".

Contact Preference
If we have questions about this form, how would you like us to contact you? (required)
Dispute Information
Debit/ATM Card Number:
Transaction Date:
Amount Charged to Account:
Payee (party debiting the account as shown on the bank statement):
Why is this transaction being disputed?
Transaction Details
At the time of the transaction the debit card was: (required)
What is the date the error was first noticed?
Did anyone else have authorized access to your card? (required)
Have you always had possession of the card? (required)
Do you always keep your card and PIN in a safe location? (required)
Who do you believe could have made this transaction?
Is this dispute being made because merchandise has been returned? (required)
If yes, please provide a copy of evidence of return by uploading it here.
Was a police report filed? (required)
If a report was filed, what date was it filed?
What is the name of the police department the report was filed with?
What is the police report number?
Additional Details
Please list any additional details:

I attest the above is true and correct. 

By submitting this claim I understand my debit card will be closed immediately to limit access to any further unauthorized activity.  A new card will be ordered and received in 10-12 business days.