@BCA CARDHOLDER STATEMENT OF CLAIM. SURAT PERNYATAAN PEMEGANG KARTU 10 BCA CARD CENTER / UNIT ISSUING FRAUD ‘Wisma BCA Forest, JL BSD Raye Utama Key Commerc Fela Business Lot LoL, Tegerang 15331 Indonesia PHONE :21.25910700| FAX cxiasoions ‘CARDHOLDER NAME : FERDINAND EMMANUEL EVAN ACCOUNT NUMBER :4726:70950114017 1 SOLEMNLY AND SINCERELY DECLARE THAT 1 DID NOT USE MY CREDIT CARD FOR THE FOLLOWING TRANSACTION(S): Dengan ial saya menyatakan dengan sesungguhnya bohwa sya idk perma menggunthon kat ret FURTHERMORE, I AM DISPUTING THESE CHARGES ON THE BASIS THAT Leb lant, nya mempermasalaban easaks-uansks tesebut berdasashan: |. WAS NOT AT THE MERCHANT / SHOP LOCATION AND NEVER MADE ANY TRANSACTION(S) (OW THE DATE STATED IN THE ABOVE TRANSACTION() ‘Saya tidak beraa di loka pedagang to eeebut dr ak perash melon uansks-ransasi pade tanga seperti teen ats, 2. HAVE MY CREDIT CARD WITH ME ALWAYS AND IDID NOT LOSE OR MISPLACE IT. ‘Kay ret ay sell ads pada say dan saya tidak peroh mengilangan stu sembarangan meletahhan tau enyinpannya 3.1 DID NOT AND NEVER AUTHORIZE ANY PERSON(S) TO USE OR TO SIGN BILL OR CHARGES FORM ON MY BEHALF. ‘Saya tida pemab memberikan kas atau mengijnkan crag lan unk menggunakan kart Kredi stu -mensndatogan fatur tanks ats oama saya Inka, 11 Janay 2021, “a c ) Signature /Tenda tangan PTBANK CENTRAL ASIA TBK ‘CARD CENTER : Kavling Commercial Foresta Let LI BSD City J1BSD Raya Uema, Desa Lengkong Kulo, KecmatanPagedangan, Kabupaten Tanger, “ely 021-5o920888, Scanned with CamScannerLAMPIRAN : DATA TRANSAKS! CARDHOLDER 4726470950114017 Term [trans Date/Time crass {Term Name |Country |Amount Txn 18-12-202007:57:10 __[4726470950114017 [Dose of Roses Inc us 1,495,589 fsg-12-202007:57:10 __|4726470950114017 __|HIBBETT SPORTS us 2,309,273 f1e-12-2020 05:29:05 _|4726470950114017 __|DOORDASH*BIG SHAKES HO_|US 172,612 18-12-2020.05:17:26 __|4726470950114017 _|GooGoo Wash Club-Cor__|US 282,083 [28-12-2020 05:02:07 __|4726470950114017 __|DOORDASH*BIG SHAKES HO_|US 201,525 28-12-2020 05:02:07 _|4726470950114017 __]DOORDASH*BIG SHAKES HO_[US 201,525 Total Amount 4,662,557 4 Scanned with CamScannerScanned with CamScanner