| □ | , . I dont recognize the above transaction; additional information is needed to identify the transaction. | ||
| □ | . I neither authorized nor participated in the above transaction. | ||
| □ | , . I confirm that the card was in my possession all the time. | ||
| □ | ( ) , .. , ( ) . , (expected delivery date of goods)________. I (the authorized person) have not received purchased service because the Merchant was unwilling unable to provide one. | ||
| □ | . . I have paid the transaction by alternate means, not by the card. I enclose my proof of payment. | ||
| □ | . . I have found the error in the transaction amount calculation. I enclose approving documents. | ||
| □ | ________ ________. . The amount of the transaction has been altered from ______ to_________. I enclose a copy of my receipt as a proof. | ||
| □ | . The enclosed credit voucher has not been credited to my card account. | ||
| □ | : _______:___________( ). I have been charged: _______twice: _________times for the same transaction. | ||
| □ | _______________, I have participated in the ATM transaction for the amount of ________ but: □ /have not received requested cash □ /received only part of requested cash amount of________ | ||
| □ | , . , __________( ). I have cancelled my continuous authority with the Merchant but my account is still being charged. I enclose a copy of my letter to the Merchant and confirm that the authority was cancelled of__ (date). | ||
| □ | ________ , . , . I did take part in the transaction for__ at the Merchant but I did not take part in the otter transactions charged by this Merchant. I confirm that the card was in my possession at the time they were made. | ||
| □ | , / , ______________ (., , . )___/___/___(//). _____________. I certify that I made a Hotel/Car reservation but I cancelled it by __ (phone, fax, e-mail) on the__/_/___ (DD/MM/YY). Cancellation Code is _. | ||
| □ | : . Other | ||
| (Date) | (Signature) * , 200 , . | (Phone) | |
, . , , .
