Mercer County State Bank
Unauthorized Debit Card Activity Form
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Unauthorized Debit Card Activity Form
Submitter Information
First Name (required)
Last Name (required)
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First Name:Last Name:Best Contact Number:

 
Activity Details:
Account Number:Debit Card Number:

 
Transaction Date:Amount of Debit:Payee (Party Debiting the Account)

 
(required)
Why is this transaction being disputed? (required)
(Select the appropriate error)
At the time of the transaction, my debit card was: (required)
Did anyone else have authorized access to your card? (required)
Have you always had possession of your card? (required)
Do you keep your card and PIN in a safe location? (required)
What was the date you first noticed the unauthorized activity?
Who do you believe could have made these transactions?
Is the dispute being made because merchandise has been returned? (required)
If yes, attach copy of evidence of the return.
 
0 Files uploaded:
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Was a police report filed? (required)
If a police report was filed:
On what date was it filed:Police Report Number:

 
(required)