Chargeback/Fraud Initial Notification

If a transaction has posted to your account that you believe is an error OR fraudulent, please complete and submit this notification. This form MUST be received at our office within 60 days of the statement closing date on which the transaction appears.

First Name:
A value is required.
Last Name:
A value is required.
Home Phone:
A value is required.Invalid format.
Work Phone:
Invalid format.
Email Address:
A value is required.Invalid format.
Account Number:
A value is required.
ATM/Debit or Credit Card Number:
A value is required.
Is the ATM/Debit or Credit Card in Your Posession? Yes No
Please make a selection.
Has a Police Report Been Filed? Yes No
Please make a selection.
I am disputing this transaction(s) because I believe this was: Fraudulent
Non-Fraudulent
Please make a selection.