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1、龙卡信用卡疑义交易声明（Declaration）卡号 CARD NO: 姓名 ACC NAME： 交易日期 TRANS.DATE 商户名称 MERCHANT NAME 金额 TRANS AMOUNT2011-11-26 ZOMBAIO.COM USD34.95本人对上述交易做出以下投诉 I dispute the above transaction(s) for the following reason(s)。Please investigate the matter:1、本人并无授权过上述交易。I have neither authorized nor participated in the
2、se transactions.2、重复收款。I was charged twice.3、交易金额不符，正确应为 。Amount should be 4、本人曾于上述商户签购 笔交易金额 ，但并未 签购过上述交易，且本人的信用卡从未遗失。I signed in transactions for at the named merchant，but I didnt sign in the above transaction(s) and my card was in my possession.5、本人确曾向上述酒店定房，但本人已于 (日期， 时间) 向酒店取消定房并取得一取消号码 。I made
3、 a room reservation with hotel and canceled it at (AM/PM) on (date) 。I was given the cancellation No .6、本人收到商户签发的退款单 ，但 该款至今仍未记入本人 账户。I received a credit slip from the merchant but the credit doesnt appear in my statement.7、本人已用其他方式付款（ ）现金、 （ ）支票、 （ ）其他信用卡。 （请附收据副本）。I paid the transaction by ( ) cas
4、h、( ) check、( ) other credit card.(Please enclose the payment receipt copy).8、上述商户无法或不愿向本人提供有关交易的服 务 （请于 备注栏内详细说明及附有关文件）。The merchant was unable or unwilling to provide the services requested. (please explain the details in the Comments Section and enclose supporting document).9、本人已于 (日期) 书面向上述商户提出取
5、消自 动转账授权，但该商户未按照办理（请附文件副本）。I informed the merchant to cancel my monthly/yearly agreement by writing on (date) (please enclose document copy ). Nevertheless, my account still billed.10、本人未曾收到在以上商户订购 的货物。I didnt receive the ordered merchandise at the agreed-upon location or by the agreed-upon delivery
6、 date.11、本人在 ATM 提款时，未成功（ ）；或金额有误（ ），实际取现金额为 。 I didnt receive the cash ( ), or just received a partial amount which was .12、其他。 Others:备注 Comments: .( 请用英文填写，如有必要可另附页。 Please write in English. You may attach additional sheets if necessary.)本人声明以上所言一切属实，如有不 实，愿 负一切法律责任。并同意承担因查询而引发的相关查询费用。 （普通商户单据调阅费
7、 USD5.00 或 RMB10.00）I understand the CHINA CONSTRUCTION BANK investigates alleged fraudulent or unauthorized pre-paid card usage and may refer the same to the appropriate law enforcement agency. I agree to cooperate in any prosecution of individuals of my knowledge，the statements contained hereby are true and correct in all respects。I agree to disburse the retrieval request fee in the investigation period (USD5.00 for every merchants or RMB10.00)签署 Signature 日期 Date: ( 签字式样须与申请表相符 Signature must be same as that on the Application Form )
