ATM FEE REVERSAL FORM

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. No photocopies of receipts will be accepted. Original receipts are required. *required fields.

*Name On Account

*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

PRINT FORM           CLOSE FORM

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). This ATM Fee Reversal Form and receipt(s) may be presented in person at any Resource One Credit Union service center or can be mailed to: Resource One Credit Union, Attn: REBATE DEPT, PO Box 660077, Dallas TX 75266-0077