(* )
( 7-495-747-38-88)
* (Cardholder name) ______________. ()
* (phone number) __________ ___________________________________________
* , (Card number charged)
____________________________________________. ( )
( )/the transaction in dispute
* Transaction date | * ( ) Merchant name | * Transaction amount | * Billing amount | Transaction number |
* /for the reason:
( , ). . ___________________ () | Please provide me with the copy of the transaction documentation (except for ATM cash disbursements). | |
, / .. /___________________________________________. ( POS-), , , | The transaction amount/transaction currency differs. The correct transaction amount/ currency ______________(the receipt enclosed) | |
/ 1 / ( ) " " ___________( ) 1 : : - . . ( ). - ( ). _____________( ): / ( ). | I made ATM/POI cash disbursement transaction, but: qI have not received the requested cash amount qI have received only a part of the requested cash amount_______________ | |
. . ( ): q ( ). q /. q . q ( ). , ___________________________() | I did not make the above mentioned transaction. I state that (mark the box): qOn the transaction date I was in full possession of the card (it was neither lost, nor stolen). qAt the moment of transaction the card was lost/stolen. q I neither was engaged in the transaction nor authorized anybody to make it. q I made transactions at this Merchant before (transaction list to be enclosed). I was informed that my declaration will cause the closure of my card account and pick-up of the card if used. | |
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