ពាក�េស�ើសុំេដោះ�សាយវ�វាទម�ាស់ប័ណ�

Cardholder Dispute Application Form Reset Form

កាលបរ�េច�ទ/Date: 01.Dec.2023 សាខា/Branch:

ព័ត៌មានអតិថិជន / Cardholder Information

Kong Sreypich
េឈ�ោះម�ាស់ប័ណ�/Cardholder Name:

េលខគណនី/Account Number: 0 6 9 2 8 9 2 2 5

េលខប័ណ�/Card Number: 4 3 8 2 4 7 * * * * * * 6 8 6 2

ិ ពាក់ព័ន�នឹងវ�វាទ / Details of Disputed Transaction

ព័ត៌មាន�បតិបត�ិការលម�ត

កាលបរ�េច�ទ/ េឈ�ោះអាជីវករ/ ចំនន

ួ ទឹក��ាក់�បតិបតក
ិ ារ/ េលខ�បតិបតក
ិ ារ/
No.
Transaction Date Merchant Name Transaction Amount Transaction ID

30.Nov.2023 $10 0002461233340291

30.Nov.2023 $20 0002641233340303

30.Nov.2023 $25 000264133340337

មូលេហតុៃនវ�វាទ / Dispute Reason(s)

សូមអានការពិពណ៌នាខាងេ�កោម និងគូសស��ាធីក (√) ចំេពោះមូលេហតុែដល�តូវបំផុតេទៅនឹងករណីវ�វាទរបស់េលោកអ�ក

Please read the following description and tick (√) the most appropriate reason for your dispute case.

1. ខ��ំ�ានដកសាច់��ាក់ពីម៉ាសុីនដក��ាក់ស�័យ�បវត�ិ (ATM) ប៉ុែន�ម៉ាសុីនដក��ាក់ស�័យ�បវត�ិ (ATM) មិន�ានបេ��ញ�កដាស��ាក់េឡើយ

I made cash withdrawal at the ATM but the ATM machine did not dispense any cash.
2. ខ��ំ�ានដកសាច់��ាក់ពីម៉ាសុីនដក��ាក់ស�័យ�បវត�ិ (ATM) ចំនួន ប៉ុែន�ម៉ាសុីនដក��ាក់ស�័យ�បវត�ិ (ATM)
បេ��ញសាច់��ាក់�តឹមែតចំនួន
I made cash withdrawal at the ATM in the amount of but the ATM only dispensed
an amount of
3. ខ��ំមិន�ានេធ�ើ ឬមិន�ានអនុ��ាតឱ�បុគ�លេផ�ងេធ�ើ�បតិបត�ិការខាងេលើេឡើយ។ ខ��ំអះអាងថា�បតិបត�ិការេនះ�តូវ�ានេធ�ើេឡើងេដោយគ�ាន
ការអនុ��ាតពីខ�ំ េហើយប័ណ�របស់ខ�ំស�ិតេនៅជាមួួយខ��ំ�គប់េពលែដល�បតិបត�ិការ�តូវ�ានេធ�ើេឡើង។
I did not perform nor authorize any other person to perform above transaction(s). I confirm the
transaction was charged without my consent. The card was in my possession at the time when the
transaction was made.
4. �បតិបត�ិការខាងេលើ�ានេកើតេឡើងេដោយគ�ានការយល់�ពមពីខ�ំេនោះេទ េហើយប័ណ�របស់ខ�ំ�តូវ�ានលួចឬ�ាត់េនៅ
The above transaction(s) happened without my consent. My card was lost/stolen on
កាលបរ�េច�ទ/Date: េម៉ោង/Time: ទីតាំង/Location:
✔ 5. ខ��ំ�ានទិញទំនិញឬេសវាកម�ពីអាជីវករខាងេលើ ប៉ុែន�េគមិនអាចផ�ល់ទំនិញឬេសវាកម�ដល់ខ�ំេទៅតាមទីតាំងនិងកាលបរ�េច�ទែដល�ាន
�ពមេ�ពៀងេឡើយ។ ការពិពណ៌នាអំពីទំនិញគឺ 3000$ if I pay them the money េហើយកាលបរ�េច�ទរ�ពឹងទុកៃនការទទួលទំនិញគឺ
េនៅៃថ� the same day as a payment

I purchased goods/services from the mentioned merchant but they are unable to deliver their product
or service to me by agreed location and date. The description of merchandise is 3000$ if I pay them the monyand
the expected date of receiving goods/services was on on the same day as payment 30.Nov.2023

6. ទំនិញឬេសវាកម�ែដល�តូវ�ានផ�ល់េដោយអាជីវករមិនដូចេទៅនឹងអ�ីែដល�ានពិពណ៌នា ឬទំនិញមានការ�ាក់ែបក។ ទំនិញ ឬេសវាកម�

ែដលខ��ំ�ានទូទាត់រួច មិន�តូវនឹងអ�ីែដលេយើង�ពមេ�ពៀងេនៅេពលទិញេឡើយ។ ខ��ំ�ាន�បគល់ទំនិញ�តលប់េទៅវ�ញេនៅ
ៃថ� េហើយខ��ំក៏ព�ាយាមេដោះ�សាយប��ាជាមួយអាជីវករែដរែតពួកេគមិនអាចេដោះ�សាយ�ាន។
The goods/services rendered by the merchant were not as described or defective. The item/service
which I paid for do not conform to what we agreed at the time of purchase. I returned the merchandise
on and I also attempted to resolve the problem with merchant, yet they were unable
to solve it.
7. ខ��ំ�ានលុបេចោលនូវសមាជិកភាព/ការជាវ/ការកក់ជាមួយអាជីវករខាងេលើរួចេហើយ ប៉ុែន�ពួកេគេនៅែតបន�កាត់លុយេចញពីគណនី
របស់ខ�ំ។ ៃថ�ែដល�ានលុបេចោលគឺ េម៉ោង េលខកូដ
I already cancelled the membership/subscription/booking with above merchant; however, they still
continue to bill to my card account. The cancelled date: Time:
The cancellation code:
8. ខ��ំ�ានេ�បើ��ាស់េលខកាតខាងេលើេដើម�ីេធ�ើ�បតិបត�ិការ ប៉ុែន�ចុងេ�កោយខ��ំ�ានេធ�ើការទូទាត់េដោយ
1. សាច់��ាក់ 2. មូលប�ទានប័�ត 3. េលខកាតេផ�ងេទៀត
I used the above-mentioned card number to perform the transaction; however, the final payment I paid
by:
1. Cash 2. Cheque 3. Other cards

9. ខ��ំ�ានេធ�ើ�បតិបត�ិការែតមួយប៉ុេណ�ោះ ប៉ុែន�អាជីវករ�ានេផ�ើវ�ក�យប័�តេដើម�ីកាត់លុយេចញពីគណនីកាតរបស់ខ�ំេ�ចើនជាងមួយ�បតិបត�ិ
ការ។
I authorized only one transaction but the merchant billed to charge my card account more than one.

10. ខ��ំ�ានេធ�ើ�បតិបត�ិការក��ងចំនួនទឹក��ាក់ ប៉ុេណ�ោះ ប៉ុែន�អាជីវករ�ានេផ�ើវ�ក័យប័�តេដើម�ីកាត់លុយេចញពីគណនី

របស់ខ�ំក�ងចំនួនទឹក��ាក់េផ�ង។ ចំនួនែដលខុសេនោះគឺ
I authorized the transaction in amount of only; however, the merchant billed to charge
in different amount to my card account. The different amount charged was
11. េផ�ងៗ/Others (សូមប��ាក់/please specify): All the payment is under my knowledge when I ask them to give
back my money they ignore me and demanded more money from
me

ហត�េលខា/Signature:

កាលបរ�េច�ទ/Date: 01.Dec.2023
 ការអះអាងរបស់ម�ាស់ប័ណ� / Cardholder’s Declaration

.
ខ��ំយល់�ពមឱ� ធនាគារ វ�ង (េខមបូឌា) ម ក ផ�ល់ជូនតតីយជនណាមួយនូវច�ាប់ចម�ងៃនពាក�េស�ើសុំេនះ និងឯកសារគាំ�ទេផ�ងេទៀតស�មាប់ការ

េសុើបអេង�ត និងការេដោះ�សាយវ�វាទ។/
I agree for Wing Bank (Cambodia) Plc to provide any other third party the copy of this form and other supporting
documents for investigation and dispute resolution.

ខ��ំសូមធានាអះអាងថារាល់ព័ត៌មាន និងឯកសារទាំងអស់ែដលខ��ំ�ានផ�ល់ជូនគឺពិត��ាកដ និង�តឹម�តូវ។/

I hereby represent that all information and documents that I have given are true and accurate.

ខ��ំនឹងបិទប័ណ�េហើយរាយការណ៍េទៅធនាគារភ�ាមៗេនៅេពលែដលខ��ំសង�័យថាមាន�បតិបត�ិការែក�ងបន�ំ។
ខ��ំយល់�ពម និងផ�ល់សិទ�ិជូនធនាគារក��ងការបង�ក ផ�ាក ដក ឬប��ប់ការេ�បើ��ាស់ប័ណ�និងេសវាកម�េផ�ងៗែដលពាក់ព័ន�េនៅេពលណាមួយ
េដោយមានឬគ�ានការជូនដំណឹងទុកជាមុន។/
I shall immediately block the card and report to the bank once I suspect fraudulent transactions.
I agree and authorize the bank to block, suspend, withdraw or terminate the use of card and other services to
which related at any time with or without prior notice.

ខ��ំដឹងថា ខ��ំនឹង�តូវទទួលខុស�តូវចំេពោះការពិន័យជាទឹក��ាក់ ២០ដុល�ារក��ងមួយករណីវ�វាទែដល�ានដាក់ពាក�េស�ើសុំ ចំេពោះករណីែដលខ��ំ�តូវ�ាន

េគរកេឃើញថាមានការចូលរួម ឬផ�ល់សិទ�ិឱ�អ�កេផ�ងេទៀតេធ�ើ�បតិបត�ិការខាងេលើ ឬព័ត៌មានែដលខ��ំ�ានផ�ល់គឺមិន�តឹម�តូវ។/
I am aware that I shall be responsible for a penalty fee $20 per submitted dispute, in case I have been found
participated in or authorized other person to perform the above transaction(s) or my given information is
inaccurate.

េលខទំនាក់ទំនង/Contact Number: 077679710

អាសយដ�ានអុីែម៉ល/Email Address: sreyp61111@gmail.com

ហត�េលខា/Signature:

កាលបរ�េច�ទ/Date: 01.Dec.2023