Signom

Cardholder's details

First name

Last name

Invoicing address

Postal code and city

Phone number

Email address

Customer number Customer number can be found at the top of the credit card invoice. It is 8-14 long number.

If you cannot locate your card number in the drop down box please contact your card issuer.
Your 16 digit card number is printed on your card. You can also find it on your card statement or by login in your online banking.

Card number (fill in the first six and last four digits of the 16-digit sequence of numbers in the empty fields).

XX XXXX

Details of disputed transactions

The amount of disputed transactions

Only one

More than one

Write the details of one single disputed transaction to below fields. Before the final signature you can attach invoice copy to claim.

Merchant name

Date of charge (format dd.mm.yyyy)

Charged amount

Charged original currency

When you have more than one disputed transaction, you have to attach invoice copy to claim before sign it. Mark the disputed transactions into the invoice copy.

Date of charge (format dd.mm.yyyy)

Choose the type of claim. You can attach the required appendix files to claim before you sign the claim.

I have not authorized or participated in the transactions mentioned here/marked on the attached statement. The card has been in my possession at all times. The account is closed. (If your account has not been closed please contact your bank's blocking service.)

My card was lost/stolen. I have not made or authorized the transactions mentioned here/marked on the attached statement. Police report must be attached. Please also include a detailed description of loss/theft of the card in the additional information field below

The service/order was cancelled and/or the merchant has promised a refund. Attached is a proof of cancellation, credit voucher or a confirmation from the merchant stating that credit will be issued. Cancellation date (dd.mm.yyyy)

I have not received the merchandise/service I ordered. I have attempted to solve the matter with the merchant. Attached is the order confirmation and e-mail correspondence with the merchant. Please include a detailed description of the merchandise/service ordered in the additional information field below.

Goods/services not as described. Order cancelled/goods returned. Attached is a copy of the cancellation/proof of return. Please include a detailed description of ordered goods/service and what was not as described in the additional information field below.

Goods received are counterfeit. Attached is proof from a brand representative/authorities that the goods are counterfeit. Where are the goods at the moment?

I have paid the transaction by other means/there is a difference between the charged amount and the amount on my receipt/ transaction has been charged multiple times. Attached is my transaction receipt or proof of payment by other means (eg. copy of a voucher, transaction receipt or account statement)

I made an ATM withdrawal but did not receive any cash /I made an ATM withdrawal but received only part of the cash requested. Amount received:

Hotel/car rental/travel agency has processed a delayed charge on my card which I do not accept. Please include a detailed explanation in the additional information field below.

Additional information

Please list the disputed transactions one by one in the additional information field. Alternatively you can include a list of disputed transactions in an attachment.

Signature

Add your email address and press "Continue". You will receive a confirmation message to added email address. If the process is interrupted for any reason, you can continue the signing using the signature link in email message. Please note that you will have to confirm your identity using your Internet banking details.

Email address: *

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Claim

Signature