CARDHOLDER DISPUTE FORM To, The Manager HDFC Bank Cards Division PO Box o! "#$% Thir&van'i(&r P!O!

Chennai ) #***%+! AME , -------------------------------CREDIT CARD UMBER ,

I am disputing the following transaction(s) for the reason given below and request you to settle the case(s) : DETAILS OF DISPUTED ITEM.S/ , TRA SACTIO DATE MERCHA T AME TRA SACTIO AMOU T

P0ease se0e12 2he 'os2 a33ro3ria2e one ,

I have neither authorized nor participated in the above transaction(s). I confirm that the card is still in my possession. My card was lost/stolen on and the same was reported to you on . !uplicate/Multiple billing. I have done only one transaction at the Merchant "stablishment but I was billed

times. (#ttach copy of authorized chargeslip) I have cancelled the transaction(s)/returned the goods$ but have not received credit/refund for the same (#ttach %redit &oucher/'efund note/Merchant(s letter or any form of merchant(s confirmation that the credit is due to the card account) I had received defective merchandise/goods and had returned the goods to the merchant. (#ttach %redit &oucher/'efund note/Merchant(s letter or any form of merchant(s confirmation that the credit is due to the card account) )aid by alternate means. *irst$ I gave my card for payment$ but later on paid by other means for the same transaction. I )aid by %ash (attach cash receipt/bill)/ %heque (attach %heque receipt/+an, statement)/ other card (attach chargeslip/other card statement) %ancelled Membership/-ubscription/+oo,ing. (#ttach the proof of merchant ac,nowledging the cancellation) I ordered goods/services and the same were e.pected to be delivered by date (dd/mm/yy) $ but I never received the same. (#ttach the proof of merchant ac,nowledging the cancellation) /he transaction amount incurred/authorized by me is for 's. but I was billed for 's. . (#ttach copy of authorized chargeslip) %ash was not dispensed at the #/M but I was billed for the entire amount of 's. . %ash was dispensed partially in the #/M for 's. but I was billed for the entire amount of 's. . 0thers ()lease e.plain in detail. )lease attach a separate letter if necessary)

I de10are 2ha2 a4ove given in5or'a2ion is 2r&e and 1orre12 2o '( kno60edge! I &nders2and 2ha2 I 1an 4e he0d 0ia40e 5or a00 1harges in1&rred i5 dis3&2e raised 4( 'e is 5o&nd inva0id! I agree 2o 3a( 2he 1harges 0evied 4( 2he 4ank 5or 2he sa'e in10&ding 2he 1os2 in1&rred 5or inves2iga2ion o5 '( 10ai'! The Bank 'a( 1on2a12 'e 6henever i2 re7&ires an( 5&r2her in5or'a2ion! "mail/)hone / *a.: !ate :

%ardholder1s -ignature

#dd2on %ardholder1s -ignature (If any)