ATM Error Report

Customer Information

• First Name
  OK First Name is required
• Middle Initial
  OK Middle Initial is required
• Last Name
  OK Last Name is required
• Social Security Number
  OK Social Security Number is required
• Date of Birth
  OK Date of Birth is required
• Email
  OK Email is required
• Mother's Maiden Name
  Optional OK Mother's Maiden Name is required

Address Information

• Street
  OK Street is required
• City
  OK City is required
• State AK - AlaskaAL - AlabamaAR - ArkansasAZ - ArizonaCA - CaliforniaCO - ColoradoCT - ConnecticutDC - District of ColumbiaDE - DelawareFL - FloridaGA - GeorgiaHI - HawaiiIA - IowaID - IdahoIL - IllinoisIN - IndianaKS - KansasKY - KentuckyLA - LouisianaMA - MassachusettsMD - MarylandME - MaineMI - MichiganMN - MinnesotaMO - MissouriMS - MississippiMT - MontanaNC - North CarolinaND - North DakotaNE - NebraskaNH - New HampshireNJ - New JerseyNM - New MexicoNV - NevadaNY - New YorkOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVA - VirginiaVT - VermontWA - WashingtonWI - WisconsinWV - West VirginiaWY - Wyoming
  OK State is required
• Zip
  OK Zip is required
• Cell/Home Phone
  OK Cell/Home Phone is required
• Work Phone
  OK Work Phone is required

Card Information

• Last 4 Digits of Card Number
  OK Last 4 Digits of Card Number is required
• Account Number
  OK Account Number is required

Loss Information

• Please Select One

  • Cash Never Received
  • Amount Requested Different Than Received
  OK Please Select One is required
• Amount Requested
  OK Amount Requested is required
• Amount Received
  OK Amount Received is required

• Date of Transaction

  JanFebMarAprMayJunJulAugSepOctNovDec 12345678910111213141516171819202122232425262728293031 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900
  OK Date of Transaction is required
• Location of ATM
  OK Location of ATM is required
• Error/Screen Message Displayed
  Optional OK Error/Screen Message Displayed is required

• Additional Comments
  Optional OK Additional Comments 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.

• Type your name here as your signature
  OK Signature is required
• Mother's Maiden name or Account Code
  OK Mother's Maiden name or Account Code is required

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