CARDHOLDER STATEMENT OF CLAIM

SURAT PERNYATAAN PEMEGANG KARTU

ll) : Il(,/\ L:AIti) ( liNTlill.r l)NiT lSSl-llN(j jiltAllt)

Wisrirr ll(lA linrs.n. .li. IiSl) I{l},n Uinnlil l(xv (lonrnrcrcial

f(no:jiu B sinc\s [-oli Lot. LL -lrltxrrung I51]3l, llrdonrsill

1.I t{ }Nt : 0l I -29!r )07()0

EMAIL : FRAUD_ISSUINC@BCA.CO.ID

('ATTDIOLDER N I\,1! : FACIIIVI)' SAID ABAD

ACCOUNT N tJMIll.R : 4s5{,1-10 I 0,{72400 I

FTJR]I IERI\,1OIIE, I AM DISPT-JTIN(i TI IESE CI.IARGES ON TI "fI

TJA:JIS IAT :
'E
l,cbill lnniut, saya fiompcrrnlrrifllalrl(an ttaosnl(si-(rallsaksi torsrb l h! alarkan :

l. I WAS NOT AT Tl IB it{EIlCI L N1 ,'lilIOP LOCI^ TION- AND NEVEIT i!{ADD ANY TIiANS,\Ct.l( )N(S) ON
.I.l
IE IIATE ST,,\TUII

IN THI] ABOVI TRANSACTION{S),

]. I IIAVIJ \1Y WII'TI MIi ALWAYS AND I DID NOTLoSIi 0R MISPLACIJ I1-.
''RI]DI]'CARD

:1. ! Dll) N(rl n ND NllvliR A(rrHoRlztl ANY PltRsoN(s) fo USlj olt fo stGN utLL oR cllAltc,,-s fot{M oN N4y BlilJALI...

alts namil saya.

Siunr{rrrr r' 'l iln(lI tilngiln

Disclahner:

huti hetja &k( truns ksi tilak iha lipruses,

2,L \)irka ide titns tliri (I(TP / Puspor) ltrn ka u kredit ytrg sesati rengnn occouttt ,unbet li.ttrs,
PT BANK CENTRAL ASIA TBK

CARD CENTER : Kavling Commercial Foresta Lot I.l BSD City Jl. BSD Raya Ulanla, Desa Lengkong Kulon, Kecamatan pagedangan,
Kflbupaten Tnngerang.

Telp. 15008{38
LAMPIRAN : D,^TA TR^,NSAKSI CARDLIOLDER 4556330104724001

Trnns Datc/Thnr Crdlss Tcrm Nnmc 'Icnn Country Amount Txn

l4-09-2023 l5:40:03 4556330104'724001 UBEIi *TRIP Atl 69&,629
l4-09-2023 l5:06r20 455633010472400r UBER *TRIP AU 425,928

Total nnloullt i 1,124,557