* tt"Uteory Bank *turyleory liiaftk

CARDHOTDER'S STATEMENT OT DISPUTI

ftIintr Ilong Leong Bank CARI) CENTRE
Fax No: 03-7946 8888
Emtil Add: Hl0nllne@hlbb.hongleong.commy

Date :

Cardholder Name

visa/Mastercard/AmexNo ;487 8700 Bsf A)a4

I have examined my CrediflDebit Card Statement of account and I would like to dispute the following transaction(s):-

1' /3.ar. ap / .(72<z /D /3 "( usz t

2' B-1rs. adl S 7n pa /b /s EfusueYS A-b /3Y.d Q:

(Please check the categorytsl that dqoibe the rcason for disptting the transaciion[sJ)
I confirmed that the transaction(s) billed was/were not autlorized by me and my card was in my possession and control at the
time of the said kansaction{s).

I confirmed that the transaction(s) billed was/were aot authorized by me and my card was $Qf in my possession and control at
the time of the said transaction(s).

l-l f hau" been billed more than once for t}le same traasaction.

t have paid in full for the transaction(s) by cash/cheque/other credit card (attached a copy of t]re Cash Receipt/Sales Youcher).
[-l
I did not receive credit for the enclosed credit voucher.
n
The amount of the sales draft has been wrongly charged The correct amount should be instead of
Enclosed is my copy of the sales draft prior to the alteration.

l-l t irave yet to receive the merchandise/service for the above transaction. The expected deliverylservice date was
- -
and since then my account has been
I have notified the merchant to cancel my moothly/yearly subscription on
charged times. Enclosed please find the cancellation letter.

I-l -- to request
l would like sales dra{t for my reference.

I participated in only ONE transaction ofthe above merchant locatiorl but did not engage nor authorize the above transaction
and my card was in my possession and controi as the time of the questioned transaction.

t cancelled my hotel reservation on {DD/},IM/YY) aI arlpm

[]
t do rot recognize the transaction (please tick accordingly) ( ) MerchantName ( ) Merchant Location
f]
)Transaction Date ( ) Others:

I make this solemn declaration conscientiously believing the same true and without prejudice to any party
EffECTfVE 1 APR 2011 there will be a
mlcrofilm copy charge of RM2l.20(Dtspute
fee=R1!00: 6e/o GST=RM1.20) each for

Identity Card No (Nelrlord) . "557 o)s/4 Vlsa/llasterCard/Amex should the transaction(s)

provcd to be authorlzed by the Cardholder. The
Bank wilt debit the tran$rctiotr(s) togetler rvith the
Telephone (ffi ce/Hous e/Ilandphone) , @1'/" interest if lt is found to be your transaction(s).

EmailAdd '//z.Catnz Updated 10/05/2016