URGENT! DISPUTE FORM In order for us to continue our investigation, please complete, sign and promptly return this letter via fax or mail. Kindly return this letter to us within 14 days from the card statement receipt date else we will assume the charge is in order. Please enclose statement of account or copies of documents, which is relating to the disputed charges. Sales draft retrieval fee of RM15.00 will be levied if transactions are found to be in order. The Manager, CIMB Card Centre CIMB BANK BERHAD / DIRECT ACCESS. Tel : 03 — 62047788 Fax : 03 - 23817198 Level 2, Menara SBB- Bui Damancas 6480 Kala Lampur ‘el 03 62047878 Fax : 03 - 20983690 Cardholder Name fcoour: No. esos] lst os yee ee] a] 5 [| | No | Merohant Name | Transaction | Amount (RM) | Reference Number (ARN) | Date [ I | Please tick one category that best describe your reason for disputing the transaction(s). wood | cettity that the above charge was neither made nor authorized by me or my supplementary cardholder. at | Ihave been | double J triple charg ar 4 | participated in only ONE transaction at the above merchant jocation but did not engage nor authorize the above transaction and my card was in my possession and control at the time of the questioned transaction. 4c] The enclosed credit voucher has not been applied to my account, Bt 1 | have paid for this transaction by other means and enclose my proof of payment. 6t 1 | would like to request a copy of the sales draft of the above transaction(s). | understand that there are adcitional charges levied to my account. 74 My credit card was lost / stolen on this date [ Jand time [ 1 [J Enclosed here with the police report for Bank references. al | Others, please specity Date: Signature of cardholder Name LONo (new)