: q q q
Cardholders name
( )
Cardholders phone number (e-mail)
:
Card account number
:
Transaction Date
:
Merchant Name & Location
( , POS-) _______________________________________________
Device Type (ATM, POS-terminal)
:
Transaction Amount
:
Billing Amount
(, ):
I am disputing this transaction on the basis that (please mark all applicable sections):
q , - , - ( ).
Neither me, nor anyone authorized by me, not anyone I know participated in this transaction (these transactions).
q / .
My card was lost/stolen.
q , .
My card was in my possession and I didnt give the card to a third party at the time of fraudulent use.
q .
Ive been charged twice for the same transaction.
q ( ), . .
I returned the goods for this transaction. But the enclosed credit voucher has not been credited to my account.
q ___________ ___________ , .
The transaction amount has been altered without my permission from ______ to ______. I enclosed copy of my receipt as a proof.
q . , , .
The above transaction was credit operation. I enclosed copy of my credit voucher.
q , .
(I was engaged in the transaction but I have not received purchased goods/services).
q ( )
Other (Please enclosed your explanation letter)
: q * q
() , Visa Intemational/ MasterCard Intemational, , , .
() , . () , , , ( ).
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() , .
* .
(Signature) ________________________ (Date) ____________________
______________________________________________________________
Cardholders name ( /full name filled in by Cardholder)
( )
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: __________________________________________________________
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Accepted by: Banks manager name Signature Date
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* ! , .
