Online transaction dispute form

STEP 1

Personal details of cardholder

Name and first name

IBAN

Telephone

Statement by account holder

I have reviewed the account statement and hereby declare the following:

I did not conduct the transactions listed.

I did not receive the money at the ATM.

I did not receive the product / service.

The amount was debited twice.

I received only a partial amount.

Other reasons

I received the following amount:

Reasons:

File upload 1

Further description

Further description of how the loss occurred.

STEP 2

Disputed transactions with debit card

1. Transaction

Date and time of transaction

Transaction amount in original currency