Unauthorized Debit Form | First Lockhart National Bank

Cardholder Information

Dispute Information

Claim Circumstances

Merchants and Amounts

Step 1
Cardholder Information

* Indicates Required
- Name or Organization Name*
- Date*
- Address*
- City*
- State*
- Zip*
- Home Phone*
- Work Phone
- Card Type*
  Debit Card ATM Card
  Card type is required
- Card Number*
- Account Number*
- Unauthorized Usage Location*
  ATM* Point of Sale
  Location is required
- Card Closed*
  Yes* No
  *Required for Unauthorized Use
  
  Card closed is required
- Date Closed*
Step 2
Dispute Information

* Indicates Required

Instructions You did not originally participate in transactions or lost/stolen You did originally participate

Unauthorized Use

I, the undersigned claimant declare, as appropriate that:

I did not use, nor authorize anyone else to use, the ATM or Debit Card issued to me by First Lockhart when said card was used to withdraw funds from my account at the Bank; or

I did not receive any value or benefit from proceeds of the card transaction(s) and no proceeds were applied to any use or purpose on my behalf; or

I have not arranged with the person(s) who misused the card to be reimbursed for proceeds of the card.

Furthermore, I have made available all knowledge, ideas, or suspicions, if any, or the identity of the person who wrongfully used my card and will make available any such knowledge gained in the future and agree to assist and cooperate fully, without limitation, with any investigation pertaining to this matter, whether by federal, state, local, or bank investigators, including testifying before a grand jury or in a court of law against the party responsible for the improper or unauthorized use of the ATM or Debit Card. I hereby certify by signing below that the above information is true and correct.
- Claimant's Signature* (type name)
- Name of Organization (if applicable)
A FALSE DECLARATION TO A FEDERALLY INSURED FINANCIAL INSTITUTION MAY BE A VIOLATION OF FEDERAL AND/OR STATE LAW.
Step 3
Claim Circumstances

* Indicates Required
Customer Did Not Participate in Transaction(s) or Lost/Stolen
- Please give a brief description of the circumstances of claim and conversation between merchant and cardholder.*
- Is card still in your possession?*
  Yes No
- If No, when was the card discovered missing?*
- Have you ever allowed anyone to use the card?*
  Yes No
- If Yes, who?*
- Was the PIN/Secret Code number with the card?*
  Yes No
- Who else had knowledge of the PIN/Secret Code number?
- Was a police report filed?*
  Yes No
- Case #
- Police Department
- Officer Contact Name
ATM Withdrawal Dispute

Which situation best describes your dispute?
I have no knowledge of the ATM withdrawal(s) listed below. I attempted a withdrawal; however, did not receive money from the machine. Other. Please explain below.
Dispute with Merchant - Customer Originally Participated in Transaction(s)

Any requested documentation is required for MasterCard to process your claim (i.e. receipts, proof of return, etc.)
- Have you attempted to resolve your dispute with the merchant?*
  Yes No
- Specific date of last contact
- Specify one
  In person By phone By email
- Who did you speak to?
- What was said?
- Please check the ONE category that best describes your dispute.
  
  I have no knowledge of the ATM withdrawal(s) listed below.
  
  The purchase was paid by check, cash, or other means but was still charged to my card
  Attach a copy of (a) the cash receipt, or (b) the front and back of canceled check, or (c) the copy of the other receipt.
  
  The amount I authorized differs from the amount that appears on my statement.
  Attach a copy of sales slip or invoice.
  
  I have received a credit slip from the merchant, however, credit has not appeared on my statement.
  Attach a copy of the credit slip.
  
  I did authorize the purchase, however:
  
  I did authorize the purchase, however:
  I have not received the merchandise.
  Expected receipt date:
  
  I have not received expected services.
  Attach a letter of explanation
  
  The merchandise received was returned.
  Return date:
  
  Attach proof of return
  
  I attempted to cancel purchase.
  Date of Attempt
  
  Attach copies of correspondence with merchant.
  
  The above item was billed monthly and I cancelled my service.
  Cancellation date:
  
  Attach corredpondence
  
  The purchase was a canceled hotel reservation.
  My cancellation number is:
  
  Supporting Documents
  
  Accepted formats: .pages, .doc, .docx, .pdf, .png, .jpg
  
  Select files from your computer
  or simply drag & drop them here

Merchants and Amounts

* Indicates Required

Date	Merchant	Amount ($)
mm/dd/yyyy	merchant_1	amount_1
mm/dd/yyyy	merchant_2	amount_2
mm/dd/yyyy	merchant_3	amount_3
mm/dd/yyyy	merchant_4	amount_4
mm/dd/yyyy	merchant_5	amount_5
mm/dd/yyyy	merchant_6	amount_6
mm/dd/yyyy	merchant_7	amount_7
mm/dd/yyyy	merchant_8	amount_8
mm/dd/yyyy	merchant_9	amount_9
mm/dd/yyyy	merchant_10	amount_10
mm/dd/yyyy	merchant_11	amount_11
mm/dd/yyyy	merchant_12	amount_12
mm/dd/yyyy	merchant_13	amount_13
mm/dd/yyyy	merchant_14	amount_14
mm/dd/yyyy	merchant_15	amount_15
mm/dd/yyyy	merchant_16	amount_16
mm/dd/yyyy	merchant_17	amount_17
mm/dd/yyyy	merchant_18	amount_18
mm/dd/yyyy	merchant_19	amount_19
mm/dd/yyyy	merchant_20	amount_20
mm/dd/yyyy	merchant_21	amount_21
mm/dd/yyyy	merchant_22	amount_22
mm/dd/yyyy	merchant_23	amount_23
mm/dd/yyyy	merchant_24	amount_24
date_25	merchant_25	amount_25
	Totals:	merchant_totals

You should expect resolution or provisional credit in accordance with the provisions and disclosures set forth in your card agreement.

Unauthorized Debit

Cardholder Information

Dispute Information

Unauthorized Use

Claim Circumstances

Customer Did Not Participate in Transaction(s) or Lost/Stolen

ATM Withdrawal Dispute

Dispute with Merchant - Customer Originally Participated in Transaction(s)

Supporting Documents

Merchants and Amounts