Fecha (Da

Solicitud de Gestin de Reclamos de Tarjetas de Crdito

(management application for credit card claims)

Nmero de Tarjeta (Card Number)

Tarjetahabiente (Cardholder)
Nombres y Apellidos / First Name and Last Name Cdula de Identidad o Pasaporte / Card ID op Passport Telfono Casa / Home P

Telffono Oficina / Office phone Telfono Celular (Mobile Phone) Correo Electrnico / E-mail

Por la presente manifiesto mi inconformidad sobre los consumos cargados a mi tarjeta de crdito, descritos a continuacin / I hereby certily that I do not recognize the disagreement with the fol
my credit card

Fecha Transaccion Nmero de Referencia Nombre del Comercio Monto Bs.

N
Transaction Date Reference Number Merchant Name Amount VEF

Ni yo ni otra persona autorizada por m, particip en la transaccin / Neither I, nor other person autorized by me, made the transaction(s) on my behalf
Al momento de la transaccin, las tarjetas vlidas emitidas a la cuenta estaban en mi poder o de una persona autorizada
At the time of the transaction(s) the valid cards were under my possession or with a person autorized by me

La tarjeta de crdito est en mi custodia

The credit card is in my custody Si No
Ni yo, ni otra persona autorizada por mi, particip en la transaccin de / Neither I, nor other authorized by me, made the transaction(s) of:

Orden por correo / Orden by email Orden por telfono / Order by phone

Intent realizar la transaccin mediante el Punto de Venta, pero la misma result fallida y no se complet la operacin / I tried to realize the transaction by Po
it was failed and the operation was not completed
No recuerdo haber realizado la transaccin. Necesito informacin adicional para identificarla. I dont recognize the Transaction and I need additional informa
identifying it.

La transaccin fue pagada usando otra forma de pago / The transaction(s) was (were) paid using another type of paiment

Cheque /Check Efectivo /Cash Otra cuenta, especifique/Another account, especify __________________

No se proces un crdito del cual tengo el recibo de la transaccin / I have the Credit Transaction Receipt that was not processed

Realic slo una transaccin en el comercio por / I only made one transaction at this merchant for VEF___________USD___________

La transaccin cargada ___________ veces por el mismo comercio / The transaction was charged ___________ times by the same merchant

El monto de la transaccin difiere del original, fue realizada por / The amount of the transaction differs from that of the purchase made for

VEF___________USD___________ y cargada por / and charge for VEF___________USD___________

La transaccin fue procesada con una moneda incorrecta / The transaction was processed using and incorrect currency

Cancel la reservacin el da / I cancelled the reservation on ___________mes/month ___________ ao/years ___________a las /at ___________

y me fue otorgado el numero de cancelacin/I was given the cancellation code _______________________________________________________

Intent realizar una avance de efectivo en el cajero automtico del banco / I tried to get cash advance at an ATM from bank _________________________

por VEF___________USD___________

No dispens el efectivo, pero realizo el cargo a mi cuenta / Cash was not withdraw but the amount was charged to my account

Dispens parcialmente la cantidad de / I Partially withdraw the requested amount of VEF___________USD___________

La transaccin fue cargada / The transaction was charged ___________ veces/time

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 No recib los servicios acordados. Contact al comercio el da / I did not receive the agreed services. I Contacted the merchant on

mes/month ___________ ao/year ___________ y su respuesta fue / and his response was ______________________________

No recib la mercanca solicitada al comercio en el lugar acordado en la fecha pactada/I did not receive the ordered goods on the place and I or date agreed
La mercanca recibida se encontr/Received goods were found Da ada / Damaged Defentuosa / Defective No es lo descrito / No other re
Se devolvo en fecha / It was retorned ___________mes/month ___________ ao/year ___________y continuaron cobrndolo/an contacted merchant on

mes/month ___________ ao/year ___________ y su respuesta fue / and his response was ______________________________

Rescind el servicio de Suscripcin y/o Cargo Automtico con el comercio / Cancelled the suscripction service and charge automatic the merchant

___________ el da/on ___________ mes/month ___________ ao/year ___________y su respuesta fue / and his response was _____________________
____________________________________________________________________________________________________________________________
Observaciones / Comments

Certifico que la veracidad de la informacin aqu proporcionada necesaria para procesar mi solicitud y acepto las condiciones del servicio / I do certify the information below is trudy and th
process my claim, accepting the condition of service.

Firma del Tarjetahabiente / Cardholder Signature Oficina Emisora / Issuing Branch Nombre del Asesor / Bank Office

VPAU-FO-002-1/11-13
 Fecha (Date)

eclamos de Tarjetas de Crdito

ation for credit card claims)

iente (Cardholder)
Telfono Casa / Home Phone

Correo Electrnico / E-mail

escritos a continuacin / I hereby certily that I do not recognize the disagreement with the following charges to

Monto USD
Amount USD

r I, nor other person autorized by me, made the transaction(s) on my behalf

uenta estaban en mi poder o de una persona autorizada
ossession or with a person autorized by me

her I, nor other authorized by me, made the transaction(s) of:

Orden por telfono / Order by phone

sult fallida y no se complet la operacin / I tried to realize the transaction by Point of Sale, but

para identificarla. I dont recognize the Transaction and I need additional information for

was (were) paid using another type of paiment

___________________________

he Credit Transaction Receipt that was not processed

on at this merchant for VEF___________USD___________

ansaction was charged ___________ times by the same merchant

nt of the transaction differs from that of the purchase made for

___________USD___________

was processed using and incorrect currency

mes/month ___________ ao/years ___________a las /at ___________ a p

m m
de _______________________________________________________

tried to get cash advance at an ATM from bank ______________________________

was not withdraw but the amount was charged to my account

quested amount of VEF___________USD___________

_______ veces/time
VPAU-FO-002-1/11-13
eive the agreed services. I Contacted the merchant on

his response was ______________________________

ha pactada/I did not receive the ordered goods on the place and I or date agreed

No es lo descrito / No other requerest

__ ao/year ___________y continuaron cobrndolo/an contacted merchant on

his response was ______________________________

Cancelled the suscripction service and charge automatic the merchant

__________y su respuesta fue / and his response was _________________________

______________________________________________________________________
ones / Comments

tud y acepto las condiciones del servicio / I do certify the information below is trudy and that is requested to

Nombre del Asesor / Bank Officer's Name

VPAU-FO-002-1/11-13
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