ATM/Check Card/Electronic Check/Error Resolution

Complete this form for Tran Codes: 7523, 7537, 7539, 7594, 7503, 7504, 1913, 1931

Completed by: Centralized Fraud Claims Phone Number: (866) 472-9786

Date Prepared: Apr 06, 2023 Profit Center Number:

The client deposes and says that they did not initiate the disputed transaction dated in the amount of and described
as a Purchase or Withdrawal; that they did not authorize the transaction; that they did not receive any benefits from
the transaction; that they did not furnish the access device or personal identification code to the person initiating the
transaction; that they did not act in concert with the person initiating the transaction; and that if the above described
claims to have been his/her act, it is unauthorized and fraudulent.

They will testify, declare, depose or certify to the truth of any or all of the foregoing before any competent tribunal,
officer, or person in any case now pending or that may hereafter be instituted in connection with the matter
contained in this statement.

Client Name: YESSICA G VILLANUEVA

Address: 14904 NEATH CT City: BOWIE State: MD Zip: 20716-1012

Home Phone: () - Work Phone: () -

Account Number: XXXXXXXXXXXXXX6229 Card Number:

Amount Disputed: 2000.00

Answer ALL applicable questions:

1. Was the ATM/Checkcard or check(s)* Lost ?
2. Was the ATM/Checkcard or checks Stolen?
3. Is the ATM or Checkcard in the client's possession?
4. Where is the card kept?
5. Was the PIN written on the card or elsewhere? If yes, is it missing?
6. Has the client given permission to someone else to use this
card?
If yes, name: If yes, relationship to client: Yes
7. Does client know of any possible suspects? the client got scammed
If yes, name: If yes, relationship to client:
8. Was a police report filed?
If yes, Police Department Name:
9. Has client traveled in the area where these transactions
occurred?
10. Has client dealt with this merchant before?
11. Has client attempted to resolve this with the merchant(s)?

Please comment on any information that would aid in the investigation:

By signing this form, you agree to fully cooperate with TRUIST and any law enforcement agency in investigating
and prosecuting any suspect, including filing police reports, and appearing and testifying in court.

ALL OWNERS OF THE ACCOUNT MUST SIGN BELOW:

Employee signature and Date Client signature and Date

Send via interoffice to Enterprise Fraud Management Claims Processing, Charlotte , NC, M/C: 500-99-01-86

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 ATM/Checkcard/Electronic Check/ Error Resolution
VISA requests a letter referencing all charges being disputed with an explanation why the
transactions are being disputed.

• How did the charge occur?

• Have you previously dealt with this merchant?
• Was the amount charged different than the agreed upon amount?

Below, provide a written description regarding the disputed unauthorized charges:

Proc Date Eff Date Serial Nbr Trans Code Amount DC Source Sequence

Description 2 Description 3 Description 1

04/05/2023 04/05/2023 0000000111 8278 2000.00 DR
Leilah Bukenya
PAYMENT ID BBT170657970
ZELLE PAYMENT TO

*FC4210004236229C-20230406049302*
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