Transaction Dispute Form.

Please note that for all transaction dispute cases, you should first try to resolve the issue
! directly with the merchant.

01

Contact name First Name(s)

Dmytro Pirus
Last Name

Email address dmc.pirus@gmail.com Phone No. +380959362156

16 Digit Card Number 5 1 9 4 0 6 5 0 0 0 1 6 6 6 1 9 Transaction Date 05 / 06 / 2023

Retailer Name(s) DANILLO COSTA LEITE Transaction Amount € 122.10 USD

02 Duplicate Transaction. 03 I do not recognize the transaction(s).

No documents required. Please tick the box if this is the reason for No documents required. Please tick the box if this is the reason for
your dispute. your dispute. N.B. This does not apply to Chip and Pin transactions.

04 I have received no service/merchandise or will
not receive any service/merchandise for the
transaction(s). e.g. Airline/Company ceased
trading.
(ALL OF THE BELOW DOCUMENTS ARE REQUIRED)
05 The service/merchandise I have received was not
as described or was defective.
(ALL OF THE BELOW DOCUMENTS ARE REQUIRED)
Copies of receipts, invoices or tickets.

Copies of receipts, invoices or tickets. Copies of correspondence between you and the retailer

Copies of correspondence between you and the retailer Documentation/experts opinion that verifies item not as described.

Confirmation that you will not receive the service paid for Proof that the goods were returned to retailer (postage receipt)
liquidation notice if applicable.
The website address from which the goods were purchased

06 Subscriptions/Continuous authority
transaction(s) that I have attempted to cancel, 07 A refund that I was promised was not processed
or have already cancelled, still being charged to after 30 days.
my card.

Refund, Receipt or Confirmation

Proof of cancellation

08 I paid by other means or the amounts differ. 09 Other e.g. Free Trials, Car Rentals, etc.

Proof that you have tried to resolve the matter with the retailer.
Attach receipt proving payment by other means.
Copies of receipts, invoices, agreements, tickets if available. N.B
parking fines/traffic violations are not accepted.
10 I did not receive my funds from the ATM machine.
Please note there are strict timeframes under Mastercard International Rules.
No documents required. Please tick the box if this is the reason for Any disputed transactions must be brought to our attention
your dispute. within 120 days of the date of the transaction
ATM receipt if available. I certify that the above information is accurate to the best of my knowledge

Signed Dmytro Pirus

Date / /
12.06.2023

Please return completed form and supporting documentation to:

Prepaid Financial Services, 5th Floor, 302-308 Langham House, Regent Street, London, W1B 3AT.
Or e-mail completed form and supporting documentation to: disputes@prepaidfinancialservices.com

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