Pe Department Request Number Deposit Loss Prevention Electronic Control REG-KDSN-BFDR2N * denotes Required Fists Customer information ‘Customer Name Dato Filed * CORTEXTV LLC. 032872011 Address" 200 RECTOR PL 36F Cty ‘State Zip NEW YORK NY 10280 Telephone Numbers ‘Account Type * (0y'212) 945-7252 i Veceaen © Email Address. ‘Account Number * Card Number ~ 4251143627 -4085404001862507 Customer will be notified by letter with the results ofthe investigation © ATMIPOS/Deposit - Lost/Stolen or Suspected Fraud © ATMIPOS/Deposit - Transaction Dispute oF Inquiry © Debit Card Losv’Stolen or Suspected Fraud Debit Card Transaction Dispute - Quality of Service/Merchandise © Debit Card Transaction Dispute - Processing Error Debit Card Transaction Dispute - Non-Receipt of Goods/Service Debit Card Transaction Dispute - Cancellations and Returns Debit Card Tan Dispute - Processing Error “Transaction Amount(s)" | Date(s) Posted™ 7 ‘$730 Joorze0r7 $6.90 Joz22011 Reason Code All supporting documentation must be included with the signed form CO Services or Merchandise Paid by Another Method Incorrect Transaction Amount Duplicate Processing edit Posted as Debit Debit Posted as Creait 's the Duplicate charge post for same amount as. pret charge? Yes © No1 fraud or unauthorized, please close and shred card. Debit Cards issued in TD Stores are IMMEDIATELY active forall purchases (Signature, PIN, ATM). Please send the signed form to Debit Card Operations-Investigations 02-206-01-10 (an SM is not required). TD Bank has provisionally or temporarily credited my account during the investigation, | acknowledge, the ‘amount may be debited upon notification of the investigation results. Cardholder's Signature Date BRANCH USE ONLY (Card Hot Carded * Date O Yes @ No 3282011 Bank ‘Branch (AIM Number) * Banka 2 Wall St (04-483-01-02) ‘Card obtained from Customer ~ Ext/Phone #* © Yes @ No