Return to Chrgebsek ni, HDC CARD CENTRE Fax 12-21-5794 0454 CARDHOLDER DISPUTE FORM ‘The terms and conditions for processing disputed HSBC Credit Card transaction(s) are as follows: 4. Please ensure the completion of the requirements below [Sy A cardholder Details [4 B. Transaction Details EX Csupporting Document 2. Please attach the appropriate supporting document. Return this form and the document(s) within 3 (three) working days. from the receipt date of this form to fax number as written above. Faure to do so may nogate a successtul chargeback. 3. HSBC will process the request in accordance to the applicable rules ond regulations and time lines of Visa International and MasterCard Internationa. 44. The cardholder wil be lable forthe disputed transaction and the subsequent charges should it ls proven ‘that the cardholder is able after a complete chargeback process has been done. Thereby declare that Thave read and understood the above Terms and Conditions. ‘Talso declare that the Information below ls correct and I am wiling to supply additional information for ‘further processing. (Cardholder Signature + B._ TRANSACTION DETAILS Transacion Bata [Biting Amount n TOR | GrgiaAmount 0 rT I dispute the above transactions with the following reason. Please tick one ( ) G SUPPORTING DOCUMENT 1D [Eimade ony one transaction, bat Twas charved [copy of transaction receipt ‘Thave paid by other means for this transaction. [Payment proof (cash/Goods have not been received by me. [Merchant's delivery Terms & Conditions. oO a Ey [eresievouther/ rend rl not processed to my account. [eed vouher or cet scknowedgemenE a oO oO 'Thave a transaction with same merchant amounted |caranotder copy of acknowledged rect ig recurring transaction/ subscription was cancallod on lye cpane, Se (ate oon a = merchant on” [Returned merchandise receipt to merchant oF Proper cancellation was acknowledged by merchant on |—- ,catiation acknowledgement from a hotealrfine (cancellation code)