AFFIDAVIT OF DISPUTE TRANSACTION
持卡人声明书
I, (中 / 英文姓名), undersigned, do hereby report the dispute transaction as followed: ( 本人仅此申诉下列交易)
Card Number(信用卡卡号)：
Transaction (s) in dispute(争议账款明细):
Transaction Date Merchant Name Transaction Amount
(交易日期) (商店名称) (交易金额)
2013/10/01 SOFTWAREMEDIA.COM SALT LAKE CITUS USD 1,666.76
Dispute Reason(s)(理由,请勾选一项):
□1. (本人未参与上述交易,亦未授权他人做此交易,故不同意商店向本人收取该笔款项。)I did not participate nor authorize anyone else to make the above-mentioned transaction(s). Therefore, I do not agree with the merchant to charge me the amount.
□2. (本人仅在上述商店消费过一笔,金额 , 另一笔金额 的交易非本人所为,当时卡片在本人身上,未授权他人做此交易,故不同意商店向本人收取该笔款项。)I have made only one transaction, amount , at the above-mentioned merchant. I did not participate nor authorize anyone else to make the other transaction, amount , at the merchant. At that time, I possessed my Visa/Master Card. Therefore, I do not agree with the merchant to charge me the amount.
□3. (以上交易金额与本人签账金额不符, 正确金额为 。)The above transaction amount is different from the one I signed on the transaction receipt. It should be .
□4. (本人已将商品退回,但商店并未退款,请见附件之退款单。)I have returned the merchandise, but the merchant didn’t process a credit to me. Please see the attached credit receipt.
□5. (其它理由请用中文/英文说明)Other reason(s)
