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11/08

2015 2 0 : 4 3 FAX +852 2508 9613

FlIBON BANK (HK)

LTD

0 1

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'
To;
Fubon Bank Credit Card Centre
Posuil address: 23/F, Fortress Tower, 250 King's Road, North Point, Hong Kone
Fa Number: 2508 9613

Cardtiolder^s StafeiTierit of Disputed Item


No!e:

This d o c u m e n t M U S T BE s u b m i n e d to F u b o n B . n k ( H o n g Kcng) L i m i t e d w f f h i n 6 0 days from m d i s . u t . m u s . c n o m statemenr d a i e A l l o f

15

E&3OTE0s(W'

U i n f o r m a f i o n r e d in the form is mancf.itory un!e(i$ o t h e r w i s e f i e d

Cftdit Card Number:

mmmz^fi^tmmnmm

CardWdef Nanne (Print): _

Contact Numbers

Enquiry bate:

Merchant

Iran. Date

Iran. Amount

have e ^ ^ m i n e d t h i transqctionlsj listed a b o w a n d dispute t h e itemfs) b a u : d o n rhe f o l l o w i n g reasoms):

/ *

r'teijse" / " b e i l d e Ihc apppoprlate.

'

^ " 1 ^ ^ & f ' n e f r f w p a n l c i p a i ^ d i n n o r a u t h o r i z e d 0 ^ e above tran.ct(on{s)- M y c a r d was fn my p o ^ ^ ^ l o n a n d c o n r r o i , t t h , t i m e o f t h e


questioned transaction.
'

j engaged

in o ne Transftalo n;

^-mM^^mm'^as<

o
h wever,

I was charged

fo r mo re than o nix.

The valid

( r s n ^ & a io n n u m b e r i s

^ A j T ' ^ m ^ i s ^ m ^ . ^Ams^mmMi?^
I

" ' t r a n s a c t i o n a m o u n t o n the sale slip was altered f o r f n H K $

1^5^;^HKS

'"^?'1^''''^^''?

r H K $

maHKS_~

A t t a c h e d Is my c o p y o f t h e credit car<j slip,

f3gB

^ r ^ n s . K t l o n ( , ) b u t i t d i d r.ot a p p e a r o n /r.y statement. A t t a c h e d Is m y c o p y o f the c r e d i r vouchee

_ , I o r d e r e d the merchandise; h o w e v e r , I h ^ v e n o t yer received i i . A n a c h e c l is m y c o p y o f t h e o r t i e r ferr

-'

fsmimmrb'

m.mB^m^

I t ^ t u m < , d mcrchar^dis^ o r c a n c e l e d safviC6.< t h i ^ t d i d n o t ma^ch how d e s c r i b e d o n the transaction receipt or other d e c u m e n t i t i o n presented
a"hL?i/Tie o f fhe purchase^AR.ached is m y p r o o f o f f e r u m / c a n c e l l a f i o r ^ a n d transaction r - x e i p t copy

^H^issfffii
j

mh^i^ _^s/ m^i^^mmmxi'^^i^.

>

O t h e r , Please specify ,

nmmmm-m

(mysf be idenfiea! l a the Jg,-.(ituiC' siync'd i riie l > i c k o f y o u f Cfcdis CArd.

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CCA u n 07/2011

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