I, the undersigned claimant declare, as appropriate that:
I did not use, nor authorize anyone else to use, the ATM or Debit Card issued to me by The First National Bank when said card was used to withdraw funds from my account at the Bank; or
I did not receive any value or benefit from proceeds of the card transaction(s) and no proceeds were applied to any use or purpose on my behalf; or
I have not arranged with the person(s) who misused the card to be reimbursed for proceeds of the card.
Furthermore, I have made available all knowledge, ideas, or suspicions, if any, or the identity of the person who wrongfully used my card and will make available any such knowledge gained in the future and agree to assist and cooperate fully, without limitation, with any investigation pertaining to this matter, whether by federal, state, local, or bank investigators, including testifying before a grand jury or in a court of law against the party responsible for the improper or unauthorized use of the ATM or Debit Card.
I hereby certify by signing below that the above information is true and correct.
A FALSE DECLARATION TO A FEDERALLY INSURED FINANCIAL INSTITUTION MAY BE A VIOLATION OF FEDERAL AND/OR STATE LAW.
Any requested documentation is required for MasterCard to process your claim (i.e. receipts, proof of return, etc.)
Please check the ONE category that best describes your dispute.
Attach a copy of (a) the cash receipt, or (b) the front and back of canceled check, or (c) the copy of the other receipt.
Attach a copy of sales slip or invoice.
Attach a copy of the credit slip.
Attach a letter of explanation
Attach proof of return
Attach copies of correspondence with merchant.
You should expect resolution or provisional credit in accordance with the provisions and disclosures set forth in your card agreement.