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UNAUTHORIZED ELECTRONIC ACH FORM
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UNAUTHORIZED ATM/DEBIT CARD TRANSACTION FORM
flagstar.com
Rev 4/17 • Member FDIC
Page 1
Please note: If fraud is suspected, the ATM/Debit card may be inactivated after submitting this form.
To order a replacement card, please call (888) 248-6423.
Date :
Card Number (last four digits): # Account Number (last four digits): #
Customer Name:
Address: City, State, Zip:
Daytime Phone: Evening Phone: Email:
Transaction Date: Amount: Party Debiting the Account:
$
$
$
$
Note: Additional spaces available on page 2. Will additional spaces be utilized? q Yes q No
Please select one option below. Reason selected must apply to all transactions, if not you must submit separate form(s):
q I did not authorize the party listed above to debit my account.
q I revoked the authorization I had given to the party listed above to debit my account before the debit was initiated.
q My account was debited before the date I authorized the transaction to occur.
q My account was debited for an amount different than I authorized.
q My check was improperly processed electronically.
ATM/Debit Card Transactions
Please select one option below. Reason selected must apply to all transactions, if not you must submit separate form(s):
q I have not authorized or participated in this transaction. My card was q in my possession or reported: q lost q stolen on .
q The withdrawal amount received $ was different than requested $ .
q I participated in one transaction at the merchant location, but NOT the transaction listed. I, or someone authorized by me, was in possession &
control of all cards at the time of the transaction. The authorized transaction amount is $ on .
q The amount billed is incorrect. I have enclosed my copy of the sales slip dated The correct amount is $ .
q The charge listed was a single transaction but has posted times to my account.
q The merchant continues to charge my account for a recurring payment that I canceled on via phone in writing.
q I contracted with the merchant for services (described below) to be provided on . I have not received them. I have contacted
the merchant in order to resolve the dispute to no avail.
q Merchandise/services rendered were not as described (see details below). I q returned -or- q attempted to return the merchandise and I
contacted the merchant on to attempt to resolve this to no avail. (Please enclose a copy of the shipping receipt, if applicable.)
Explanation/Comments (Please send/attach additional sheet(s) as necessary):
I am an authorized signer, or otherwise have authority to act, on the account identified in this statement. I attest that the debit(s) above was not originated with
fraudulent intent by me or any person acting in concert with me. I have read this statement in its entirety and attest that the information provided on this statement is
true and correct and that the signature below is my own proper signature and acknowledge receipt of a copy, which should be retained for my records.
Authorized Signor’s Signature: Date:
For internal use only.
Employee Name: Branch: ATM ID#
Notes:
IMPORTANT INFORMATION
Once complete and signed, please mail, email, or fax to:
Mail: Card Services | Mail Stop 4-316 | 301 W. Michigan Avenue
|
Jackson, MI 49201
Email: Disputes@flagstar.com Fax:
(
248
)
250-5409
click to sign
signature
click to edit
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