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Dispute Declaration Form-1

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tobbie.ntuli
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14 views

Dispute Declaration Form-1

Uploaded by

tobbie.ntuli
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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TRUWORTHS

CREDIT SERVICES - FRAUD DEPARTMENT


Tel: 021-4602230 Fax: 0864323154 Email:[email protected]

DISPUTED PURCHASE / ACCOUNT DECLARATION


SURNAME & INITIALS: Ntuli L
………………………………………………………………… DATE: ……../……../……..
30 Jan 2019

ID NUMBER: 9 0 0 1 0 9 0 9 4 2 0 8 6
ACCOUNT NUMBER: 1 3 7 4 4 8 3 9 2 1
HOME TEL NO: ( …. ) …………… 031 3061110
WORK TEL NO: ( …. ) …………… CELL:
0836172866
………..……………
THE DISPUTE IS AS A RESULT OF THE FOLLOWING (TICK THE APPROPRIATE BLOCK/S)

1. YOU DID NOT OPEN THE ACCOUNT 3. ID BOOK LOST/STOLEN

2. CHARGE CARD WAS LOST OR STOLEN 4. DRIVER'S LICENCE LOST/STOLEN

** Disputed Purchases - please provide details of transactions


On the 25 January at Game city one of the store spice I recognise my back is open and I check my
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….
Wallet was not there, inside the wallet there was 2 Id book, grant card, capitec card, Mr price card
……………………………………………………………………………………………………………………………………….

If your Chargecard/ID/Driver's Licence was LOST/STOLEN, please complete the following:

DATE REPORTED:
25Jan 2019
……../……../…….. STORE NAME:
Gorimas store spice
……………………………………..

Are you able to give any information which will help solve the dispute?
I didn't see some who take this but I'm sure the time I enter at the my wallet was there
……………………………………………………………………………………………………………………………………

Has any other fraud been committed in your name at any other retailer?
No
……………………………………………………………………………………………………………………………………

Do you have any information about the person/s who committed the fraud? Y N
If Yes, please provide details of person
……………………………………………………………………………………………………………………………………
No
……………………………………………………………………………………………………………………………………

URGENT PLEASE NOTE : In order for us to complete our investigation we require you to fax/email us copies of
the following:

1. Copy of your ID (Smartcard back & front) 2. Copy of your chargecard (back & front)

FAILURE TO PROVIDE THESE REQUIRED DOCUMENTS WITHIN 7 DAYS OF YOUR DISPUTE CAN RESULT IN YOU BEING HELD LIABLE FOR THE ACCOUNT

I hereby declare that the information supplied in this form is true and correct and undertake to convey any further
information which may come to my attention, to assist you in the resolution of the above matter.

Home
SIGNED AT: ………………………………… DATE:
30 Jan 2019
……../……../……../

SIGNATURE ………………………………………………….. WITNESS ………………………………………..


Njabulo Bane

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