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HSBC CARDHOLDER DISPUTE FORM

To: Cardholder Dispute & Chargeback Section, HSBC Card Services, 8/F Tower 2 & 3 HSBC Centre, 1 Sham M o n g R o a d , K i n

:12 & 38
Facsimile(852) 2269 3080
Your reference number
.(Please fill in your card

Credit card number

Trans date

Disputed amount

Trans amount

Merchant name

number

I refer to the above transaction(s) and advise that (Please select the dhpuie reason listed below.)

5.)
I have neither made nor authorised the above transaction(s).

I did not make any reservation(s) with the merchant.

with cancellation code

I made the reservation w i t h the merchant, I cancelled i t on

I paid the above transaction(s) b y o t h e r credit card no.


/ c a s h / c h e q u e w i t h number
A copy o f the
Cash receipt/ C h e q u e /
bank statement is enclosed.

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/()

The merchant made an addition or transposition error. I enclose the transaction receipt copy i n support.

The transaction amount has been altered f r o m


The cardholder copy o f the transaction receipt is enclosed.

to

without m y consent

I have received a credit transaction receipt(s) from the merchant. However, no credit was posted to my card account. A
copy of the credit slip is enclosed.

The merchandise was to be shipped. I received i t and returned i t back to the merchant. The merchant did not properly
disclose a l i m i t e d return policy at the time o f transaction and no credit was received. A copy o f the relevant document/s is
enclosed

''

.12

Your reference number

-2-

I have requested for the termination o f the service w i t h the merchant on


by
Letter/ E - m a i l /
facsimile. A copy o f t h e termination document is enclosed for your action. Please request the merchant to stop
further billings.

/()/()

I have neither made nor authorised the transactions and w i l l not accept any subsequent transactions posted after the above
one.

I have neither made nor authorised the above transaction (transaction receipt no.
). I was still
in possession and control o f all valid cards at the time o f the transaction. 1 only authorised the transaction amount o f
on
(transaction receipt no.
)

7fc.(
;i^iHi 1#

I did engage i n the above transactioti(s) but I did not receive the requested cash I
for the amount o f

I only received part o f t h e cash

/(

I or my authorised person did not receive the service / merchandise from the merchant. A copy of the order f o r m is
enclosed.

/
The merchandise / service received is not as described as the one I ordered/purchased from the merchant.

(Please specify how the merchandise is not as described and provide relevant proof t o show the
difference / cieffectiveness)

/()/''
(
The order I made was i n
merchant is i n

(state currency, example, C N Y ) . However, the transaction wrongly charged by


(state currency, example, U S D ) .

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)"1

Other Dispute reason (please specify i n details)

3().

Signature

Cardholder's name W ^ J\ M . ^ .
Date

Contact number

Note: Please sign and return this form to the above facsimile number within fourteen days. Should you have any questions, please
feel free to contact us on (852) 2288 3194.

:'(852) 2288 3194

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