牡丹卡账务查询申明书

附表1：

牡牡牡

丹丹丹

卡卡卡

账账账

务务务

查查查

询询询

申申申

明明明

书书书

交易总额(Trans Amount)：（如为多笔交易，请提供对账单复印件勾明具体交易）(Multiple 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)：
□ATM交易(ATM Transaction) □POS 交易(POS Transaction) □其他(Other)
2.□调阅单据，原因如下( Transaction Receipt Retrieval)
□记账金额与实际消费金额不符 The amount billed is incorrect. The Transaction Amount should be ____ not _____.

□ATM未吐钞已记账 ATM does not dispense
□重复记账▁次 The charge listed was a single transaction but was posted ____ times to my account
□实际消费未成功，账户已被扣帐 Transaction was unsuccessful, but the amount have posted to my account
□存款未达帐，存款单附后 Cash deposit did not post to my account, enclosed a copy of the deposit receipt
□退货交易未到帐，退货单据附后 Credit did not post to my account, I have enclosed a copy of the credit issued□无法回想起交易情况，请调取交易单据供本人查验 I did not recognize the transaction, please provide the copy of the transaction receipt
□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, the account number was used fraudulently.

□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 attempted to resolve this dispute with the merchant.

□本人尝试与商户联系要求退还所购货物，但遭到商户拒绝。I want to return the merchandise, I have contacted the merchant to resolved the dispute and the merchant refused to:_____ Adjust the price _____ Repair of replace the goods or other things of value _____ Issue a credit.

□该笔消费本人已经以其他方式付过款，付款凭证附后，本人已经尝试与商户解决该争议。The charge listed was paid previously by another method. I am enclosing proof. I have tried to resolve this with the merchant.

□本人已取消该预定，取消日期_____，取消号码______。I am disputing a guaranteed reservation service. Date of cancellation______, cancellation number______.

3.□利息及费用收取方式有误，要求调整(Interest & Commission Adjustment)
□利息(Interest) □取现费(Cash withdrawal Fee) □滞纳金(Overdue Fee) □超限费(Over Limit Fee) □其他(Other)具体说明（对以上问题的详细描述）Please provide specific explanation about the above inquiry:

本人陈述：上述情况属实，本人愿意承担由此产生的一切法律后果；若查明确为本人交易，本人愿意支付业务处理中所产生的费用。(By completing this form, you assert that the information included is accurate to the best of your knowledge. If you admit the requested transaction, it means that you authorized the bank to charge the commission for inquiry to your account.)

重要提示：Important alert:

1、牡丹信用卡客户服务中心热线: 95588，以上操作只收取本地话费。原件请您妥善保存，以备查询。

1. ICBC Card Center hotline: 95588. The above services only charge for the local phone call. The original copy shall be kept properly for further enquiries.

2、调单收费标准：国内交易副本10元/份。国外交易副本5美元/份。

2. Fee for retrieval request: 10 RMB/ domestic transaction copy. 5USD/ overseas transaction copy.

3、为了维护您的正当权益，请您在拒付期限内提出申请。您的调单或拒付申请日距该笔交易的交易清算日不能超过60天，

超过此期限的申请恕无法受理。如您在当月10日前未收到上月对账单（上月无交易发生除外），请您及时与客户服务中心联

系，要求补打账单，但调单或拒付期限仍按正常收到账单日计算。

3. To safeguard your rights and interests, please submit applications within the term of chargeback. The application date should not be more than 60 days later than the settlement date of the transaction. The application later than this can not be processed. If you have not received the billing statement of previous month before 10th of the current month, please contact the customer service center and ask for reprinting. However, the time frame of retrieval and chargeback is calculated as the billing statement has been received normally.

4、为使您得到及时的服务，请您务必按照上述格式填写，确保内容真实、准确、完整。

4. In order to enjoy in-time services, please fill in authentic, accurate and complete information as specified.

5、银行在收到您的调单或拒付申请后与您确认，并将尽快向您通知调单或拒付情况，如您未得到回复，请及时与牡丹卡客

服中心联系。

5. After receiving the application for retrieval or chargeback, the bank will confirm with you and inform you about the results ASAP. In case of no reply, please contact ICBC Card Center in time.

6、请您按照对账单通知的还款金额及时还款，以免影响您的信用记录。如拒付成功，将对您的账户进行调整（另有说明的

除外）。

6. Please repay the amount specified on the billing statement to keep your credit record intact. If the chargeback is processed successful, your account will be adjusted accordingly (not otherwise specified).

7、如拒付申请中途撤销，调单费用不予退回
7. If the application for retrieval is revoked in the process, the expenses will not be returened.

本人所持卡号

卡片有效期，现申明在（日期）

（国家或地区）

(商户名称)交易总额为的交易非本人交易，即交易非本人所为，本