¢VGÎYG êPƒ‰ Dispute Form _____________________ / _________ / _________:ïjQÉJ Date:_________ / _________ / _____________________ Name:________________________________________________________________________ ___________________________________________________________________________:º°S’G Transaction Amount:_________________________________________________________ ______________________________________________________________________:á«∏ª©dG ≠∏Ñe _____________________ / _________ / _________:á«∏ª©dG ïjQÉJ Transaction Date:_________ / _________ / _____________________ Merchant Name (Owner Name):____________________________________________ _________________________________________________________:(ôLÉàdG º°SG) AGô°ûdG π Card Number:________________________________________________________________ ______________________________________________________________________:ábÉ£ÑdG ºbQ I acknowledge receipt of my statement dated _________ / _________ / _____________________, in which I found that the above transaction(s) has been charged erroneously; please investigate and take appropriate action. 1. I did not authorise or participate in the transaction(s), please block my card and replace it to avoid illegal transaction(s). 2. I did only one transaction for _________________________________ but did not perform the other transaction(s), and I confirm that my card was not lost and was in my possession at all times. 3. I ordered goods/services from the above merchant, which I have not received. I tried to solve it with the merchant but he did not reply (As per the attached). 4. The merchant issued a credit voucher in my favour which has not been credited to the card (a copy of the credit voucher attached). 5. I paid the mentioned amount by (Cash/cheque/other credit card). PLease find enclosed a proof of payment. 6. I am not sure of the mentioned transaction(s). I need a copy of the sale(s) voucher. If the transaction(s) is (are) correct, I agree to pay the service charges for copy request as follows: a. Each voucher for airlines/travel agencies/car rental/hotels SAR 100. b. Each sale voucher for others SAR 25. 7. I cancelled my subscription with the mentioned merchant before the billing of the transaction. Attached is a proof of cancellation. 8. I have cancelled my reservation in the mentioned hotel within the allowed period of cancellation as per the hotel policy (Attached proof of cancellation). 9. Other: _______________________________________________________________________ _______________________________________________________________________________ I prefer sending correspondence to be via: Email: ___________________________________________________________________________ or Regular mail to my mailing address according to Bank records. Note: Please fax/e-mail your dispute letter to 011 276 3437 or [email protected] I hereby declare that the above information is true and fully understand that my disputed amount(s) was (were) refunded to me temporarily until the case is resolved. The bank will re-bill the dispute amount to my card if the transaction is correct and I will pay the agreed service charges as mentioned above. I take all responsibility for correspondence through e-mail. ïjQÉàH á«fÉªàF’G »àbÉ£H ÜÉ°ùM ∞°ûµd »eÓà°SG ºµd ócDhCG ÒZ (äÉ«∏ªY) á«∏ªY ÜÉ°ùàMG ” å«M _____________________ / _________ / _________ (äÉ«∏ª©dG) á«∏ª©dG áë°U øe ≥≤ëàdG ƒLQCÉa √ÉfOCG Qƒcòe »°VGÎYG ÖÑ°S ¿CÉH Ék ª∏Y ,áë«ë°U .ΩRÓdG AGôLE’G PÉîJGh Öæéàd É¡dGóÑà°SGh ábÉ£ÑdG ±É≤jEG AÉLôdG ,á«∏ª©dG ΩGóîà°SÉH á¡L hCG ¢üî°T …CG ¢VƒaCG ⁄ .1 .áYhô°ûe Ò¨dG äÉ«∏ª©dG QGôµJ ⁄h QƒcòŸG πëŸG iód §≤a ~~~~~~~~~ ≠∏ÑÃ á«∏ª©dG âeóîà°SG .2 ™«ªL »`a »JRƒëH ábÉ£ÑdG âfÉch ïjQÉàdG ¢ùØf »`a iôNCG (äÉ«∏ªY) á«∏ªY …CG Ωóîà°SCG .äÉbhC’G ™e ¿B’G ≈àM á©∏°ùdG º∏à°SCG ⁄ øµdh QƒcòŸG ôLÉàdG øe äÉeóN /áYÉ°†H Ö∏£H âªb ó≤d .3 OQ ¿hO øµdh É¡«∏Y ≥ØàŸG IóŸG ∫ÓN á©∏°ùdG ∫É°üjE’ ∂dPh ôLÉàdG ™e á©HÉàŸÉH âªb ÊCG º∏©dG .(≥aôeh Éªc) ¬aôW øe IQƒ°U ≥aôe) ¿B’G ≈àM ábÉ£ÑdG ¤EG ™LÎ°ùj ⁄h ≠∏ÑŸG ´ÉLQEÉH kGóæà°ùe QƒcòŸG πëŸG ‹ Qó°UCG .4 .(óæ°ùdG ºµd ≥aQCGh (iôNCG á«fÉªàFG ábÉ£H /∂«°T /kGó≤f ) iôNCG ¥ô£H AGô°ûdG á«∏ªY ójó°ùàH âªb .5 .OGó°ùdG âÑãjÉe ™aO ≈∏Y ≥aGhCG É¡àë°U ±É°ûàcG ádÉM »`ah É¡∏«°UÉØJ ójQCGh (äÉ«∏ª©dG) á«∏ª©dG øe ócCÉàe ÒZ .6 : ‹ÉàdÉc ∂dP ∞«dÉµJ .¢S.Q 100 ¥OÉæa /äGQÉ«°S ÒLCÉJ/áMÉ«°S /¿GÒW äÉcô°T øe á«∏ªY πc π«°UÉØJ .CG .¢S.Q 25 iôNCG á«∏ªY πc π«°UÉØJ .Ü .≥aôŸG Ö°ùM ∂dPh á«∏ª©dG º°üN πÑb QƒcòŸG ôLÉàdG iód »àjƒ°†Y AÉ¨dEÉH âªb .7 íFGƒd øª°V É¡H ìƒª°ùŸG IÎØdG ∫ÓN ∂dPh QƒcòŸG ¥óæØdG ™e õé◊G AÉ¨dEÉH âªb .8 .(õé◊G AÉ¨dEG âÑãj Ée ≥aôe) ¥óæØdG ________________________________________________________________________ :iôNCG .9 _______________________________________________________________________________ q G :≥jôW øY π°UGƒàdG π°†aC ____________________________________________________________________ :ÊhÎµdE’G ójÈdG .∂æÑdG iód ±ôq ©e ƒg Éªc …ójÈdG »bhóæ°U ójÈdG hCG 011 276 3437 ºbQ ¢ùcÉa ≈∏Y ¢VGÎY’G ∫É°SQEG AÉLôdG :á¶MÓe [email protected] ÊhÎµdE’G ≈àM áàbDƒe IÎØd ¿ƒµj OÉ©j ≠∏Ñe …CG ¿CÉH ∑QOCGh áë«ë°U √ÓYCG áë°VƒŸG äÉeƒ∏©ŸG ¿CÉH ôbCG º°üN ™e áë«ë°U á«∏ª©dG âfÉc GPG ≠∏ÑŸG º°üN IOÉYEG »`a ≥◊G ∂æÑ∏dh ,á«FÉ¡ædG èFÉàædG ô¡¶J .kÉ≤HÉ°S IQƒcòŸG Ωƒ°SôdG .ÊhÎµdE’G ójÈdG ≥jôW øY π°UGƒàdG óæY á«dhDƒ°ùŸG πeÉc πª–CG »æfCG Éªc Work Tel.:_______________________________________________________________________ _________________________________________________________________________:πª©dG ∞JÉg Mobile:___________________________________________________________________________ _____________________________________________________________________________:∫Gƒ÷G _____________________________________ Signature ™«bƒàdG