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1、招商银行信用卡持卡人疑问交易声明书填写指南尊敬的客户:您好！请您参照本指南填写附页招商银行信用卡持卡人疑问交易声明书：一、请您将疑问交易发生的卡号及持卡人姓名填写至相应栏位；超商根行|像用卡中心招商银行 CHINA MERCHANTS BANK持卡人声明仁CARDHOLDERS STATEMENT持卡人姓名C/H NAMEW一 张三一 f信用卡卡号 Card No.: J-339188* 1236二、请您将疑问交易的交易日期、商户名称及金额在表格中逐笔 填写;本人委托招商银行将下列声明及相关文件交于商户所屈的收单银行，代本人反映争议款行。(请写下争议款项的明细并在符合您申明的情况前打“M”)!
2、 entrust China Merchants Bank to transfer this statement and related documents to the acquirer banks and dispute the payments below on my behalf.(Please write down the details of the dispurejransactions and choose your proper condition with 11 V .)交易日期一 Frans.date商户名称 MERCHANT NAME金额TRANS AMOUNT-201
3、3 J)823_WALMART.COM_JJSD1 翁傅一请您参照如下账单中的对应栏位:交易日期TRANS. DATE交易日；商户名称MERCHANT NAME交易摘要;金额TRANS AMOUNT人民币金额（境内）美金金额（境外）a记赅日Post Ite产市金嵌、卡号末四位 产8Vt 4 digits）交易地点 Country /Area交易地金薇Origmal TransAmount/ Descriptioti08130814北京京东世纪信息技术有限公司- 18.00I 3969CN-18.0008150816衷付宝快捷支勺(95188 ) 96 .00/ 3969CN96.00 0815
4、 /0816北京京东世磁；息技术有限公司 789.00/ 3969CN789.000820上海整瓦蟋信息咨询有限公司3969CN80.00三、请在1-7选项中，勾选符合您疑问交易的情况，如有其他情况或需补充说明，请勾选8选项并作详细叙述，如有必要可另附页；)i.本人声明从未授权过上述消费，且未授权他人使用此卡，也未透露过信用卡数据予他人.本人一直依 从贵行约定条款妥善保管本人的信用卡.I assert that 1 have never participated in or authorized the above mentioned transaction. And 1 neither ma
5、de it nor authorized any one to make the above stated transaction(s), and the card was in my possession at the lime of the disputed transaclion(s).).()2.本人确实于 年一月_日到过此商店，并消费了一笔金额(美金/人民币)，但上述款项并非本人的消贽。本人一直遵守贵行约定的条款，妥善保管本人的信用卡，且卡片一直在身上，并未借 予或授权他人使用.1 really went to this shop or(date), and made the tra
6、nsaction in amount of(RMB/USD). But I did not involve in the above mentioned transaction and always kept the card with me. never lent or deiegaied ii to the others.()3.本人声明已参与上述交易，但此笔交易已用其他方式支付，()现金、()支票、()其他卡.(若有 发票或其它凭证，请附上。若您已与商户联系反映，请于备注栏填写您与商户的联系情况说明).This transaction has been paid by ( )cash、(
7、)check、( ) other card(s). (Please enclose the invoice or other receipt and explain the details in the Commenis Section if available).()4.本人己于 年一月一日撤销此笔交易(),或已于 年_月_日退货(若有交易撤销或退货凭证，请附上。若您已与商户联系反映，请于备注栏处填写您与商户的联系情况说明)1 have cancelled this transaction on(date) ( ), or have returned the sales on(date)()
8、. (Please enclose the cancellationretum voucher and explain the details in the Comments Section if available).()5.上述款项在本月账单中重豆和帐，消费_笔,扣款一笔.、I was duplicated charged. I only 而示ie ransacuon(s). but was charged transactions.7)6.本人声明已参与上述交易,但商无法或不愿向本人提供有关交易的货物倔务(请于备注栏内详细 说明并填写您与商户的联系情况说明).The merchant w
9、as unabk_nnufiwilluig40 provide the mere hand i sse rv i ces requested. (Please explain the details in the Comments Section).() 7.本人提取现金 (人民币，美元)，吐钞 (,人民币，美元)。l-didnt receive the cash ( ) , or just received a partial amount which was(RMBAJSD).()8.若非上述情况或需补充说明,请详细叙述于下Please list more detailed informa
10、lion as fbllowing:LfidhL receive ihe merchandise 】ordered. I concaclcd the merchant by email and the merchant replied that they cant deliver it t。ee since it is out of sale. Please see the contact informaiion attached. I refused Lo pay this charge.四、请您务必在签署栏中亲笔签名（打印无效）并注明填写日期;签名需与信用卡背面签名相符。招寄板行I京川卡中心 n V* I C4iJ CIO*-and criminal liability _ _ _持卡人签名Signature：布上 .(谓与信用卡背面签名相符)(Signature must be same as that on the back of the card) 签名日期QaE:“冉年L月？日