To~ : The Hongkong and Shanghai Banking Corporation Limited lfiiJ:lfiiiiiiiU'Tfim*Rl

Cardholder Dispute and Chargeback Section, Card Centre: 8/F Tower 2 & 3 HSBC Centre, 1 Sham Mong Road, Kowloon
~m~~~.2~~-~m:ftn~~,~~-~~~2~&~3~s

HSBC CARDHOLDER DISPUTE FORM )II.

Note 11' : Please tick where applicable.

mff ~ J5 ~,Ell T-- 5C. ~ ~ ~ ~ ~ ~

llHEiAli:(I';J!tU5!Jn.t~~.

Credit Card Number 1i ffl -HMlll

Bank Reference Number

Transaction Date
3'UHlJOl

Merchant Name

mn-t~;m

Transaction Amount
3UU:f1li

i!li.P~ii

Disputed Amount
~HU:Ili

I refer to the above transaction(s) and advise that (Please select the dispute reason listed below.)
N~L~~~m~ . *Am~~ .

(N~#m6~$MDm.)

I have neither made nor authorised the above transaction(s). *A:tt~Ul9.\Gllllft!!AilJ;J.L~~.

I did not make any reservation(s) with the merchant. *A~~iaJJiti!li.P'!UHfm .

I made the reservation with the merchant, I cancelled it on _ _ _ _ _ _ __ _ _ with cancellation code _ _ _ _ _ _ _ _ __

I paid the above transaction(s) by *A 8 ffl

0
D
0

other credit card

~ft!!ffiffl~

(number ;m!l _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __

cash m~
cheque 1<:Jll (number ;m11 _ _ _ _ _ __ _

5<1-jP).Lillli .

A copy of the
m~~~L

cash receipt
m~~~*

cheque
1<:l!Hl~*

bank statement
,EI

is enclosed.

~-~~*

The merchant made an addition or transposition error. I enclose the transaction receipt copy in support.
i!li.Pm~~ro~ . m~~~L*~*J;J.~~~ .

The transaction amount has been altered from _ _ _ __ _ _ _ __ _ _ _ _ to _ _ _ _ _ _ _ _ _ _ _ _ _ without my

consent. The cardholder copy of the transaction receipt is enclosed.

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. *A~~i!li.Plii~ti<:JlUI:~BJl., ffi.*AI~ffi*~i~i!li.P!':Jl!~ . m~~~ L l!~HfB.!l1~*

The merchandise was to be shipped. I received it and returned it back to the merchant. The merchant did not properly disclose a limited return
policy at the time of transaction and no credit was received. A copy of the relevant document/sis enclosed.
*A8~~!':J~~~~l!~Mi!li.P,ffi.ffi*~~l!~ . tt~~-.illi.P*~&-*Al!~~~ . m~~~L~AX# .

I have requested for the termination of the service with the merchant on _ _ _ __ _ _ _ _ __ by 0 letter 0 email
A copy of the termination document is enclosed for your action. Please request the merchant to stop further billings.

facsimile.

Page >iO.: 112

CPD278-m (1012 15) FW

I have neither made nor authorised the transactions and will not accept any subsequent transactions posted after the above one.
*A~*~-A*~~~~.~-~#~8~~-~ff~~~ o

I have neither made nor authorised the above transaction (transaction receipt number _ _ __ __ _ _ _ _ _ _ _ _ ). I was still in
possession and control of all valid cards at the time of the transaction. I only authorised the transaction amount of _ _ _ _ _ _ _ _ __
on _ __ _ _ __ __ _ __ _ (transaction receipt number - - - -- - - - - - - - - - ).
*A~*~-A*P.U~~ (

*UUJ;m!l ________ ) o 1'~~* , *A~ii!ll-F-OO:Eil*A~~o

_ ___ S *~~~--------- ( *M.;m!l ________ ) o

I did engage in the above transaction(s) but

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

I did not receive the requested cash

*AR~----

I only received part of the cash for the amount of

*A~A*~~~~-~~5'~~~~~ 0 m~~M~rr~m* o

The merchandise/service received is not as described as the one I ordered/purchased from the merchant.
*A~~~~ t m5~*A~D~IT(UI)~~~tm5~~~ . ~~~~z4~~~*~ o

Please specifY how the merchandise is not as described and provide relevant proof to show the difference/defectiveness. !#f.111it'f'Fal.:ZJ8&/6f1Utlllfllj/j.

The order I made was in

in

(state currency, example, CNY). However, the transaction wrongly charged by merchant is
(state currency, example, USD).

Other dispute reason (please specifY in details) : *~mt~

Signature

i#ili!ff) :

Cardholder N arne

~-FA~ '8

Date S IOl

Contact Telephone Number

lllll$!\f,!i;m!l

X
Note: Please sign and return this form to the above address within fourteen days. Should you have any questions, please feel free to contact us on (852) 2288 2533 .
iltllllcllli'P). l:"<~ ;lU'l'l:ilt;l1!ili:~H!I E1 PliiDliiiPI<rr o Jillll!tl!lll , ill!: 'II (852) 2288 2533 ll!li .

i'tt :

Page

HSBC CARDHOLDER DISPUTE FORM )IIIUIHT.ff.F~ffl-t~~li:JI~'ili*

Ji~

2/2

CPD278-m (101215) FW