be CIMBNIAGA UP: FAX/email ‘atara, SURAT PERNVATAAN PEMEGANG KARTU ‘CARDHOLDER STATEMENT Saya ying brandatann dak in Theda tr Guibenerfane” —-'}- RIFANDO PANGGABEAN Nonortan tt ; Camcmitimie > 4284160311062302 Dengn in ssya menyataten menyangga ransasitrnsa Brkt yang tla agian hepa saa, Herey declare th om espn he folowing charges) tha as bee ils omy rec. Ne] Tangaat Tass Taper Tans Tomi Tans Traction Date Merchant Nome Teamscton Amount a Tage Pa Rea ‘Saya menyanagh denen alan sebog era (ling yngetal Tem spating is hese for reson): as ee erat a ar a ine oreeeete nesters tee alae 2. Saya haya melakan call vasa! cup ebstankan bi dr sek Tengegelin one transaction, however wae charged mare then one 3. Ada peruban jemi anak Say hanya mak rasa ebesorRp. ukanebasr Rp, bukit) Transaction emu changed. ony have the rasan of Rp Pad af Rp, reef eaten. 4 Suymtelah metayac dengan tnt kat red in uk terme ‘hve aly eh oer ret end, (poof enclose) 5, Transits! el dipaancleh mech, sla copy pembutlan voi sled. ‘Transaction bas been canceled by merchant, enclsed copy of ol sles deaf. 6. _Siyamelatakan uaa ATM dts ep, (isk menrins aang yng disherdakianya mensinasebgian sr ung yang étgiie). Partpated in the ATM transaction (3) above ut, dna receive the esh este reso e portion of cath reqestd. 7. Alasan nya (els (er reason ec). Lengtapideng foo copy Kanu tres dan KTP zon Beltars Preseecloe con feel card and denatin card, Boh sds. ‘Saya menataan bab pernyatsan dl ats ber dan dapat di penangang janaban ‘Thereby declare tha the above tteient core and relia. “anges / Date, ‘ ) “Tondatmngin Penepang Kane (Condhtier Signature cata Never 1 Saya baseia memberia dolumen trbshan asa proses poyeidanslnjutye Tages tose abtional dcuments for further nsigaton. 2 Say bert diteraan bya sees Rp 50.00, prtrnsaks, pai see proses peneliikan erate Wasa tesa dab rans ea apres to be charged Rp. 50.008 po teansaton if the ansacton fs genuine fom my card. Penge Kim ys apt dipros apa let tsdxang leh perezang Kum, ‘Dispute wil be processed is sgne by Cardholder. 4, Mobon Kara Kredi psn taglan pla magnet, chip an 3 nga dibolalong kar aihgu Please cut the cre cad on magnetic spe the chip prt and ease the thee scary number Behind the card.