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Report a Lost/Stolen Card

ACH (Electronic) Transaction Dispute Form

THIS IS NOT FOR DEBIT CARD TRANSACTIONS

Member Information

Name

First Name

Last Name

Member Number

Daytime Phone

(###)

###

####

Email

Transaction Information

Enter details about the unauthorized or improper ACH transaction

Date ACH Debit Occurred

MM

DD

YYYY

Name of Person or Entity Debiting Account

Account Number (if applicable)

Check # (if applicable)

Dollar Amount of Transaction

$

Additional Facts about the Transaction

Form Submission

*Required Field