????????? (????????????????). ????????????? ?? ????????????????? ?? ???????????????? cardholder dispute form
(???????????????? ?? ???????????????? ?? ??????????????????????? ?? ?????????????????? ??????????????????????? ?????????????????? ????????????????
????????????? visa (mastercard))
???????????????? 2
?? ??????????????? ?? ??????????????????????? ?? ??????????????????
??????????????????????? ?????????????????? ????????????????
????????????? VISA (MASTERCARD)
N ____ ??? "__"___________ 200_ ??.
------------ ------------- -----------------
???????: ? ??????????: ? ??????????????: ?
-----------+---------+-----------+-----------+---------------+----
Bank: City: Branch:
------------
??????????: ?
-----------+------------------------------------------------------
Address:
--------------------
???????????? ???????: ?
-------------------+----------------------------------------------
Cardholder
------------
??????????: ?
-----------+------------------------------------------------------
Address
-------------------- ---------------------
??????????? ????????? N:? ?????????????? ????????? N:?
-------------------+-------------+-------------------+------------
Office telephone N Home telephone N
--------------------
????????????? ???????: ?
-------------------+----------------------------------------------
Card name:
-------------------- ---------------------
???????? N: ? ??????????????? ????? ?
-------------------+-------------+-------------------+------------
Card N Account number
????????????? ?? ????????????????? ?? ????????????????
Cardholder dispute form
??, ?????????? ????????????????? ????? ??????????????? (???????????????) ????????????????? ??????, ?????????????? ??
???????????? ???? ??????? (????????????????? ?? ??????????????) ???????????????, ?? ?????????????? ?? ??? ?????????????. ??
??????????? ????????????? (???????????? ??????????):
I have noticed on my billing statement(s) attached those transactions that are not
authorized by me and are fraudulent. I declare the following:
???? ??, ???? ?????-??????, ???????????????????????? ????????, ???? ?????-??????, ????? ??????????????, ??? ??????????????? ??
????????????????? ???????????????, ??? ?????????? ?? ??? ?????????? ??????????????? ???????????-?????? ????????? ????? ??????????? ??
????????????? ??????? ??????????????? (?????? ???????????????).
I have neither authorized nor participated nor expect to receive any benefit or value
as a result of this transaction(s).
?????? ??????? ???? ???????????/?????????????. ????: "__"_______ 200_ ??.
????????: _______________________________________________________
My card was lost/stolen. Date _____________________
Location _____________________________________________________
?????? ??????? ???? ?? ??????? ???? ????????? ????????????????? ??????? ???????????????, ?? ?? ??? ????????????? ?? ??
????????? ????????.
My card was in my possession and I did not give the card to a third party at the time
of fraudulent use.
?????? ??????? ??? ??? ???? ???????????? ???????? ???? ????????? ????????????????? ??????? ???????????????.
My card was never received.
????????? ????????????????? ????? ???? ???????????? ?? ___________ ??? __________.
The amount of the sales slip was altered from ______ to ______.
?????????????? ??? ??? ???? ?? ???????? ????????? ?? ??????, ?? ????????????? ??? ???????.
Although I made the reservation with the hotel, I cancelled it.
?? ??????????????? ?? ?????????? ??????????????? ??? ?????????? ______________ ??? ??????????? ????????????????????
????????????/?????????????? "__"_______ _200_ ??., ??????????? ?? ??? ??????????????? ?? ???????????? ??????????????? (???????????
????????????????).
I did participate in one transaction for _____________ at the same merchant listed
above, however, I did not participate in the other transaction(s).
?? ????? ??? ??? ??????????? ????????? (???????????).
I have not received the merchandise (service) up to now.
?? ??????? ?????? ???????????? ????????????, ???? ?????????????? ????? ???????? ??????????? ?? ??????? ???????, ???????
????????? ??????? ???????, ?????? ??? ????????? ??? ??? ???????????????. (???????????? ??? ??????????? ?????????????? ????????,
?????????, ??????????.)
I have reasons to believe that the following individual(s) had access to my card, knew
my account number, knew my PIN without my authorization. See on the back side.
??????????.
Other.
???????????? ???????????????, ?? ?????????????? ?? ??? ?????????????.
A list of disputable transaction(s).
----------------------------------------------------------------------
?N ????? ??????????????? ????????????? ???????????????????? ?????????? ??????????????? ?
? ?Transaction Date ???????????????/???????????? ?Transaction Amount ?
? ? ?Merchant Name ? ?
+---+-----------------+-----------------------+----------------------+
?1. ? ? ? ?
+---+-----------------+-----------------------+----------------------+
?2. ? ? ? ?
+---+-----------------+-----------------------+----------------------+
?3. ? ? ? ?
+---+-----------------+-----------------------+----------------------+
?4. ? ? ? ?
+---+-----------------+-----------------------+----------------------+
?5. ? ? ? ?
----+-----------------+-----------------------+-----------------------
?????, ?????????????? ??????????? ??????????? ?? ??????? ???????.
Individuals that might had access to my card.
----------------------------------------------------------------------
?N ??.??.??. ?????????????? ???????? ??????????? ?
? ?Full Name ?Home Address ?Telephone ?
+---+------------------+-----------------------+---------------------+
?1. ? ? ? ?
+---+------------------+-----------------------+---------------------+
?2. ? ? ? ?
+---+------------------+-----------------------+---------------------+
?3. ? ? ? ?
+---+------------------+-----------------------+---------------------+
?4. ? ? ? ?
----+------------------+-----------------------+----------------------
?????? ??????????? ??????? (????? ?????????????? ??? ???????): _______________
Primary cardholder name
?????????????? ??????????? ??????? (????? ??? ???????): ______________________
Signature of primary cardholder as set on the card
?????????????? ???????????? ????????????????? ??????: __________________________
Signature of card account holder
???? ??????????????: "__"_______ _200_ ??.
Date of Declaration
|