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Citi Card Disputes Form

The cardholder is disputing a transaction on their Citibank credit card statement. They engaged in a transaction but were charged multiple times. They have filled out Citibank's dispute form selecting the option that they engaged in one transaction but were charged more than once. They have provided their card and contact details and authorized Citibank to charge a HKD50 fee per disputed transaction if the bank finds documentation justifying the transactions.

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Alex Ming
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323 views

Citi Card Disputes Form

The cardholder is disputing a transaction on their Citibank credit card statement. They engaged in a transaction but were charged multiple times. They have filled out Citibank's dispute form selecting the option that they engaged in one transaction but were charged more than once. They have provided their card and contact details and authorized Citibank to charge a HKD50 fee per disputed transaction if the bank finds documentation justifying the transactions.

Uploaded by

Alex Ming
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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To: Citibank (Hong Kong) Limited – Interchange Dispute Department

11/F Citi Tower, One Bay East, 83 Hoi Bun Road, Kwun Tong, Kowloon, Hong Kong
致: 花旗銀行 - 清算部 香港九龍觀塘海濱道 83 號花旗大樓十一樓
CARDHOLDER’S STATEMENT OF DISPUTED ITEM 持 卡 人爭 議 交 易 聲 明
Citibank ATM Card 提款卡 # / Credit Card Number 信用卡號碼 :
Name of Merchant 商戶姓名 :

Transaction Date 交易日期 Transaction Amount 交易金額

If your transaction is not authorized, please contact our CitiPhone Banking Hotline (852) 2860 0333 before submission.
如閣下之爭議交易未經授權，在遞交前，請聯絡花旗銀行電話理財服務熱線 (852) 2860 0333。
I have examined the transaction(s) above and would like to dispute the item(s) based on the following reason (Please tick the most appropriate
box) 本人對上述之交易作出以下之聲明 (請在適當之方格內填上√ - 只可選一項):

( ) I engaged in one transaction; however, I was charged for more than once.
本人只參與一宗交易，但卻被商戶收款一次以上。
( ) I certify that I neither participated in nor authorized the above transaction(s). My card was in my possession and control at the time of the
questioned transaction.
本人並沒有參與上述之交易或對其給予授權，並且本人之提款卡/信用卡沒有被盜竊或遺失。
( ) The transaction amount on the sales slip was altered from HK$ ________________ to HK$ ________________ . Attached is my copy of the
sales voucher.
簽賬單據之交易金額由 HK$ ________________ 更改為 HK$ ________________ (現附上簽賬單據副本)。
( ) I received a credit slip for the above transactions but it did not appear on my statement. Attached is my copy of the credit voucher.
本人收到商戶簽發的退款單，但至今該退款仍未存入本人之賬戶 (現附上退款單副本)。
( ) The credit voucher was processed as a sales transaction on my statement. Attached is my copy of the credit voucher.
退款單在月結單上錯誤當作為簽賬交易，(現附上退款單副本) 於________________ (日期) 。
( ) On ________________ (date), I ordered the merchandise, however, I have not yet received it. Please credit the amount to my account. Attached
is my copy of the order form.
本人於________________ (日期)訂購之商品，未能按原定日期收到。請將有關金額存入本人的賬戶 (現附上訂購表格副本)。
( ) I engaged in the transaction, but I cancelled on __________________ (date) with a cancellation number _______________________. Attached
is the copy of cancellation notice.
本人已於_________________ (日期)向商戶取消有關交易並附以取消號碼 __________________ (現附上取消通知副本)。
( ) I engaged in the transaction and have settled by other means. However, my card account was charged. Attached is the proof of payment by other
means.
本人已用其他方式繳付有關交易金額，但本人的提款卡賬戶仍然被誌賬 (現附上其他方式繳付交易單據副本)。
( ) Service is not rendered due to inability or unwillingness of merchant. I have attempted to resolve the dispute with the merchant. The date
services were to be provided for was __________________. Attached is the written notice from merchant / media coverage.
商戶無法或不願意向本人提供有關交易之服務。本人已向商戶作出追討。有關服務應於 __________________ 提供。(現附上商
戶之書面通知/媒體報導)。

( ) Other reason (please specify): _______________________________________________________________________________________

其他原因(請詳細說明) : _______________________________________________________________________________________
If the bank receives appropriate documentation justifying the transactions, I hereby agree the bank to impose a handling fee of HKD50.00 per dispute transaction to my
account. 如經調查，銀行有足夠的文件以證明交易，本人同意銀行於本人的賬戶扣除每項爭議交易HKD50手續費。

Cardholder Name Cardholder Signature


: :
持卡人姓名 持卡人簽 署
Contact Phone Number
Date 日 期 : :
聯絡電話號碼
Please return your completed form via a computer, tablet or mobile device by uploading at www.citibank.com.hk/card-form Other Credit Card
Service Forms  Cardholder’s Statement of Disputed Item or mail in to the address above.
請將已填妥的表格透過電腦、平板電腦或流動裝置上載至www.citibank.com.hk/card-form 其他信用卡服務表格 持卡人爭議交易聲明，或郵寄
到上述地址。
* Must be the same as the one on your Citibank ATM Card/Credit Card signature panel 須與閣下 Citibank 提款卡/信用卡之簽字式樣相符。
# Applicable for ATM Card with purchase function only 只適用於具有簽賬功能之提款卡。

For Bank Use Only 銀 行 專 用 : Processing Branch Code: Customer No.#


( ) In person, ID S.V. by: (S.V. signature on
( ) Mail in ( ) Messenger System Input by:
Verified the card back):
Case Ref./檔案編號:

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