Application for contesting the transaction due to suspected fraud

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*
Additional phone number

Transaction details:

The card number (first 6 and last 4 digits)*
Date and time of start of transactions*
Transaction amount*

Attention: If there is more than one transaction, please indicate the list of transactions, the total amount and number and dates of transactions and the name of the service where the transactions were made in the comment field. Also, please attach a screenshot or a statement showing the transactions below in the field for attaching documents.

Transaction location *

Please describe the details of the circumstances that caused the need to dispute the transaction*
Attach scanned copies of receipts and other documents confirming the transaction. Upload files in the following formats here: png/jpg/doc/docx/pdf/mp3/mp4/mov/m4a up to 25 MB.
Not selected

The Bank is not responsible for the outcome of the appeal in case of failure to provide the client, or late submission of all necessary documents / explanations (specified in the form) for the appeal process.

The screen provided by FUIB's Online program is not a document that can be used as a justification for initiating an appeal.