Application to dispute the transaction at an ATM

The form is for the first request only. It is not used for repeated requests for the same transaction.

General information about a Customer:

Full name*

TIN (Tax identification number)*

Phone number*

Email*

Transaction details:

The card number (first 6 and last 4 digits)*

Date and time of the transaction*

Withdrawal amount*

Please describe the details of the circumstances that caused the need to dispute the transaction*

I understand and agree that if this claim is granted, the disputing transaction funds will be credited to my current account without the Bank sending a written response to this appeal.