附表1： 牡 丹 卡 账 务 查 询 申 明 书.doc

附表1: 牡丹卡账务查询申明书
Transaction Inquiry Form
*卡号(Card No.): *卡片有效期(Exp Date): *交易日期(Trans Date):
交易国家或地区(Trans Country/District)): *商户名称(Merchant Name):
*交易总额(Trans Amount): *交易币种(Trans Currency): (如为三笔(含)以上交易,请提供对账单复印件勾明具体交易)(With no less than three disputed transactions, please mark the transaction amount on the copy of the statement respectively)
*查询类型(Transaction Type):
□消费(Consumption) □取现(Cash Withdrawal) □转账(Account Transfer) □利息及费用(Interest & Commission)
*查询交易币种(Trans Currency):□人民币(RMB) □外币(Foreign Currency)
*查询内容(Choice of Inquiry):
1. □查询交易场所(Transaction Location )/商户名称(Merchant Name):
2. □调阅单据,原因如下( Transaction Receipt Retrieval)
□非本人交易(指交易非本人所为,亦未授权他人使用,卡在本人手中) Neither I, nor anyone else authorized by me engaged in this transaction. My credit card is in my possession,and the account number was used fraudulently.
………………以上调阅单据原因须填写《非本人交易附加说明》,以下无需填写《非本人交易附加说明》…………………………
□记账金额与实际交易金额不符,交易金额为_____,不应为_____. The amount billed is incorrect. The Transaction Amount should be ____ not _____.
□实际消费未成功,账户已被扣账 Transaction was essful, but the amount was debited to my account
□退货交易未到账,退货凭证□有□无 The amount of the refunded goods has not been credited to my account.
□定期付费交易已于_____日取消,但商户仍继续定期向本人账户中收费,本人已经尝试过与商户解决该问题。The merchant continues to charge my account for periodic billings to my account that I canceled on _____. I was speaking with ______ (if know) and have a