HSBC CARDHOLDER DISPUTE FORM

To: Cardholder Dispute & Chargeback Section, HSBC Card Services, 8/F Tower 2 & 3 HSBC Centre, 1 Sham MongRoad , K i n

:12 & 38

Facsimile(852) 2269 3080

Your reference number

Credit card number .(Please fill in your card number

Trans date

Merchant name

Trans amount

Disputed amount

I refer to the above transaction(s) and advise that (Please select the dhpuie reason listed below.) 5.)

I have neither made nor authorised the above transaction(s).

I did not make any reservation(s) with the merchant.

I made the reservation wi th the merchant, I cancelled i t on

.

with cancellation code

I paid the above transaction(s) by o t h e r credit card no. / cash / cheque wi th number

A copy o f the Cash receipt/ Cheque / bank statement is enclosed.

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The merchant made an addition or transposition error. I enclose the transaction receipt copy in support.

The transaction amount has been altered f rom

The cardholder copy of the transaction receipt is enclosed.

to without my consent

I have received a credit transaction receipt(s) from the merchant. However, no credit was posted to my card account. A

copy of the credit slip is enclosed.

The merchandise was to be shipped. I received i t and returned i t back to the merchant. The merchant did not properly

disclose a l imi ted return policy at the time o f transaction and no credit was received. A copy of the relevant document/s is

enclosed

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Your reference number

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I have requested for the termination o f the service wi th the merchant on by Letter/ E - m a i l /

facsimile. A copy o f the termination document is enclosed for your action. Please request the merchant to stop

further billings.

/()/()

I have neither made nor authorised the transactions and w i l l not accept any subsequent transactions posted after the above

one.

I have neither made nor authorised the above transaction (transaction receipt no. ). I was sti l l

in possession and control of all valid cards at the time of the transaction. 1 only authorised the transaction amount of

on (transaction receipt no. )

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I did engage in the above transactioti(s) but I did not receive the requested cash I I only received part o f the cash

for the amount o f .

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I or my authorised person did not receive the service / merchandise f rom the merchant. A copy of the order f o rm is

enclosed.

/

The merchandise / service received is not as described as the one I ordered/purchased from the merchant.

(Please specify how the merchandise is not as described and provide relevant proof to show the

difference / cieffectiveness)

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The order I made was in (state currency, example, CNY) . However, the transaction wrongly charged by

merchant is in (state currency, example, USD).

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Other Dispute reason (please specify in details)

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Signature .

Cardholder's name W^J \M.^ .

Date .

Contact number . Note: Please sign and return this form to the above facsimile number within fourteen days. Should you have any questions, please

feel free to contact us on (852) 2288 3194.

:'(852) 2288 3194