R1CU

ATM FEE REVERSAL FORM

* Indicates a Required Field

Name on the Account: *

Member Number:*

Account Number:

E-mail Address:

Transaction Date *

Surcharge Amount *

/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
/ (mm/dd) $ .
  Total: $



Signature: *

Date:

 

Please do not send multiple requests for the same ATM fee reversals.

ATM fee reversal requests must be submitted within 30 days of the date of your ATM transaction.

Your ATM fee reversal(s) will be processed upon receipt of all required information. This ATM Fee Reversal Form must include original ATM receipt(s). No photocopies of receipts will be accepted.

This ATM Fee Reversal Form and receipt(s) may be presented:

In person at any Resource One Credit Union branch or

Mailed to: Resource One Credit Union, Attn: REBATE DEPT, PO Box 660077, Dallas TX 75266-0077