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Fields
ATM Fraud Form
Name
*
First Name
*
Last Name
*
Member Number
*
Last Four Digits of Card Number
*
Phone Number
*
Email
*
How many fraudulent/unauthorized transaction(s) are you submitting?
*
One
Multiple
Date
*
ATM Location
*
Amount
*
Date
ATM Location
Amount
Date
ATM Location
Amount
Select one of the Following:
*
Lost/Stolen: My card is no longer in my possession.
Counterfeit: I have my card, but transactions have occurred without my consent.
Have you ever shared your PIN with anyone?
*
Yes
No
If yes, who (Name)
*
Additional comments
*
Acknowledgement
*
I confirm the information contained in this document is truthful. I acknowledge SECU may release the information contained herein to law enforcement officials for investigative purposes.
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