Académique Documents
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24/03/2015
1 0 : 0 7 : 1 4 AM
e
Att ntion
PAGE
1/001
Fax
P a x
Server
No. 2296
Cardholder N ainc
Transaction Date
Merchant N ame
T e l . N o.
StatcmcW Date
Transaction Amount
Part I )
'1
would like to dispule llie ite m(s) base d on the fo]lowing re ason(s):(Ple ase
*
- K// m-'C
(M
Unauthorized Use - Internet / Mailing Order/ Pho ne Order transactio n o nly I neither iiutho fized no r participated in the above [ransaclio n(s;). My card ma in niy
possession at the time o f tlie queslio iied transaclio n. (Phase enclo se co py o f (he front md back o f your
airdj
...........H............1.'.........................^^^.....$.1.......7^
(Pflh
Participated in
poss
e ssion at the time of the questioned U'aiisaction. (Plcrfse enclose copy ofthe
(msactm)
-ffi > )3
Duplicated Charge
ony
aulhoi ized one U'im saction but ihe merchanl charged m ore than once.
/-^$
-
Incorrect Amount / Transaction Currency
(
(
in
cash or
(Currency),
(Currency) was not agree lo use, merchant did not offer a choice to me for
(Pkase enclose copy oft he t mnsnct ion receipt )
receipt )
'11
Credit Not Receive: I have re ce ive d a credit slip issue d by the merchant but no refund is received. (Plam e nclose
docum
e nl)
ffi >
to provide the ordered me rchandise / se rvice s lo me, I have aue nipte d to resolve with the
dcUmy
date )
.
.
()ilffiWW >(
Cancelled Recurring Services I have informed the mercham lo cancel my direci debit authoiization agreement on
.still billed. (Pkase e nclose the amcellafm
e
e
l tt r/form)
()
Cancelled Reservation at Hotel have made a room reservation at the nbove Hotel but cancelled al
(ani/pm) on
Cancellation N o.
qyuD
'' e
I will settle above Ii ansRclion(s) first, please refund lo me i f I am iioi liable for the transaclion(s).
^K-
I will n o l settle the transaction(sX please put the transaction on hold until the investigation results are known. I understand that I w i l l be liable for tlie disputed item
together with the handling fee ( i f nny) and accru&d inleresl, il" Ihe IransaclionCs) is proved to be authorized by me.
CardholderSignalure:
Date:
c n o i i j o j 30530