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*

Transaction details:

The card number (first 6 and last 4 digits)*
Date and time of the transaction*
Withdrawal amount*
The dispute reason*
Please describe the details of the circumstances that caused the need to dispute the transaction*