Reg E Dispute Intake Form

Intake form for capturing a consumer electronic fund transfer (EFT) error claim, including transaction details, date noticed, and unauthorized transaction statement.

Submission Notice

• What happens after I submit?
  Your submission will be reviewed by the dispute team. We may contact you for additional details, and we will use the information provided to investigate the claimed EFT error or unauthorized transaction.
• I understand and consent to the use of my information for dispute investigation

Consumer Information

• Full Name
• Preferred Contact Email
• Preferred Contact Phone
• Account Last 4 Digits
  Enter only the last 4 digits of the account involved.

Dispute Details

• Type of Issue
• Date of Transaction
• Date You Noticed the Issue
• Transaction Amount
• Merchant or Payee Name
  If known, provide the name shown on the transaction.
• Describe the error or unauthorized activity
  Include what you expected to happen, what actually happened, and any relevant dates or details.

Unauthorized Transaction Statement

• Did you authorize this transaction?
• Was your card, phone, or device in your possession at the time?
• Do you know the person or party involved?
• Statement of Unauthorized Transaction
  Describe why you believe the transaction was unauthorized and any steps you took to protect your account.

Supporting Information

• Have you already contacted the merchant or payee?
• Upload Supporting Documents
  Examples: transaction screenshots, statements, or correspondence. Do not upload full account numbers or passwords.
• Additional Notes