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Erence Number I received my billing statement on ________ (mmddyy) for the month of ________ (mmyy) and do not agree with the transaction/s stated above due to the following reason/s: (copies of documentation/s attached) Please check appropriate reason of dispute: I am not sure of the transaction and am requesting for a copy of the sales draft. I have been charged twice / thrice Support Documents Needed: 1.Cardholder’s copy of Saleslip For Retail Transaction 2.Cardholder’s copy of ATM Recei.

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