CARDHOLDER DISPUTE FORM

Chargeback & Dispute Resolution Unit

Date :

Branch :

Cardholder Name : Account / CIF

Card Number : Civil ID

No Transaction Date Merchant Name and Country Amount US$ Statement Date
1

Please tick √ the one that is most appropriate and ensure that you attach the corresponding documentation.

1 √ I authorize Commercial Bank of Kuwait to debit my account / card with the administration fee KD 2 per
transaction to cover the cost in investigating the dispute.
‫ﻙ‬.‫ﺩ‬2/- ‫ﺑﺭﺟﺎء ﺗﺯﻭﻳﺩﻱ ﺑﻧﺳﺧﺔ ﻣﻥ ﺇﻳﺻﺎﻝ ﺍﻟﺷﺭﺍء ﺍﻟﺧﺎﺹ ﺑﺎﻟﻣﻌﺎﻣﻠﺔ ﺍﻟﻣﺫﻛﻭﺭﺓ ﺃﻋﻼﻩ‬
2 I have been charged more than once for the same transaction.
‫ﺗﻡ ﺍﻟﺧﺻﻡ ﻣﻥ ﺣﺳﺎﺑﻲ ﺃﻛﺛﺭ ﻣﻥ ﻣﺭﺓ ﻋﻥ ﻧﻔﺱ ﺍﻟﻣﻌﺎﻣﻠﺔ‬
3 I participated in an ATM Cash disbursement but did not receive the requested amount / received
only a portion of the requested amount.
‫ ﺍﺳﺗﻠﻣﺕ ﺟﺯء ﻓﻘﻁ ﻣﻥ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﻁﻠﻭﺏ‬/ ‫ ﻟﻡ ﺃﺳﺗﻠﻡ ﺍﻟﻣﺑﻠﻎ ﺍﻟﻣﻁﻠﻭﺏ‬،‫ﺑﻳﻧﻣﺎ ﻛﻧﺕ ﺃﻗﻭﻡ ﺑﺎﻟﺳﺣﺏ ﺍﻟﻧﻘﺩﻱ ﻣﻥ ﺟﻬﺎﺯ ﺍﻟﺳﺣﺏ ﺍﻵﻟﻲ‬
4 I have neither participated nor authorized the above transaction(s).
‫ ﻭﻟﻡ ﺃﺻﺭﺡ ﺑﻬﺎ‬،‫ﻟﻡ ﺃﻗﻡ ﺑﺈﺟﺭﺍء ﺃﻱ ﻣﻥ ﺍﻟﻣﻌﺎﻣﻼﺕ ﺍﻟﻣﺫﻛﻭﺭﺓ ﺃﻋﻼ‬
a The card was lost / stolen and was reported / not reported to the Bank.
‫ ﻟﻡ ﻳﺗﻡ ﺇﺑﻼﻍ ﺍﻟﺑﻧﻙ ﺑﺫﻟﻙ‬/ ‫ﺳﺭﻗﺕ ﻭﺗﻡ ﺇﺑﻼﻍ ﺍﻟﺑﻧﻙ ﺑﺫﻟﻙ‬ ُ / ‫ﻓُﻘﺩﺕ ﻣﻧﻲ ﺍﻟﺑﻁﺎﻗﺔ‬
b I confirm that at no time the card was out of my possession.
‫ﺃﺅﻛﺩ ﺃﻥ ﺍﻟﺑﻁﺎﻗﺔ ﻟﻡ ﺗﻛﻥ ﺑﺣﻭﺯﺓ ﻏﻳﺭﻱ ﻣﻁﻠﻘًﺎ‬
5 I have not authorized the above mentioned internet/mail/phone order transaction(s).
‫ ﺍﻟﻬﺎﺗﻑ‬/ ‫ ﺍﻟﺑﺭﻳﺩ‬/ ‫ﻟﻡ ﺃﻓﻭﺽ ﺃﺣﺩﺍ ً ﺑﺈﺟﺭﺍء ﺃﻭﺍﻣﺭ ﺍﻟﻣﻌﺎﻣﻠﺔ ﺍﻟﻣﺫﻛﻭﺭﺓ ﺃﻋﻼﻩ ﻋﻥ ﻁﺭﻳﻖ ﺍﻹﻧﺗﺭﻧﺕ‬
6 I confirm that I have participated in the transaction dated __________ but not participated in the
disputed transaction(s) taken place.
‫ ﻓﻘﺩ ﻛﺎﻧﺕ ﺍﻟﺑﻁﺎﻗﺔ ﺑﺣﻭﺯﺗﻲ ﻓﻲ ﻭﻗﺕ ﺇﺟﺭﺍء‬.‫ﺃﻗﺭ ﺑﺄﻧﻧﻲ ﻗﺩ ﻗﻣﺕ ﺑﺈﺟﺭﺍء ﺍﻟﻣﻌﺎﻣﻠﻪ ﺍﻟﻣﺅﺭﺧﺔ ﻓﻲ _________ ﻭﻟﻛﻧﻧﻲ ﻟﻡ ﺃﻗﻡ ﺑﺈﺟﺭﺍء ﺍﻟﻣﻌﺎﻣﻠﻪ ﺍﻟﻣﻌﺗﺭﺽ ﻋﻠﻳﻬﺎ‬
.‫ﺍﻟﻣﻌﺎﻣﻠﺔ ﺍﻟﻣﻌﺗﺭﺽ ﻋﻠﻳﻬﺎ‬
7 A credit reversal from the above merchant is due to me for which I have not been credited
(attached is the credit voucher).
(‫ ﺣﻳﺙ ﻟﻡ ﻳﺗﻡ ﻗﻳﺩ ﺍﻟﻣﺑﻠﻎ ﻓﻲ ﺣﺳﺎﺑﻲ )ﻣﺭﻓﻖ ﺇﺷﻌﺎﺭ ﺍﻹﻳﺩﺍﻉ‬،‫ﻳُﺳﺗﺣﻖ ﺇﺟﺭﺍء ﻗﻳﺩ ﻋﻛﺳﻲ ﻟﻲ ﻣﻥ ﺍﻟﺗﺎﺟﺭ ﺍﻟﻣﺫﻛﻭﺭ ﺃﻋﻼﻩ‬
8 I have been debited for a transaction that has been paid by other means (cash/cheque/money
transfer/ other credit cards). Attached is proof of payment.
‫ ﻣﺭﻓﻖ ﺇﺛﺑﺎﺕ ﺍﻟﺩﻓﻊ‬.(‫ﺑﻁﺎﻗﺎﺕ ﺍﺋﺗﻣﺎﻧﻳﺔ ﺃﺧﺭﻯ‬/‫ﺗﺣﻭﻳﻝ ﺃﻣﻭﺍﻝ‬/‫ﺷﻳﻙ‬/‫ﺗﻡ ﺍﻟﺧﺻﻡ ﻣﻧﻲ ﻋﻠﻰ ﻣﻌﺎﻣﻠﺔ ﺗﻡ ﺩﻓﻊ ﻗﻳﻣﺗﻬﺎ ﻣﻥ ﺧﻼﻝ ﻭﺳﺎﺋﻝ ﺃﺧﺭﻯ )ﻧﻘﺩﻱ‬
9 I have not received the goods ordered for the above amount.
.‫ﻟﻡ ﺃﺳﺗﻠﻡ ﺍﻟﺑﺿﺎﺋﻊ ﺍﻟﻣﻁﻠﻭﺑﺔ ﺑﺎﻟﻣﺑﻠﻎ ﺍﻟﻣﺫﻛﻭﺭ ﺃﻋﻼﻩ‬
10 The merchandise received was not as described, poor quality, damaged, or unsuitable for the
purpose intended. I have contacted the merchant and their response to the return was _________.
‫ ﻗﻣﺕ ﺑﺎﻹﺗﺻﺎﻝ ﺑﺎﻟﺗﺎﺟﺭ ﻭ ﻛﺎﻥ ﺭﺩﻩ ﻋﻠﻰ‬.‫ ﺑﻬﺎ ﺃﺿﺭﺍﺭ ﺃﻭ ﻏﻳﺭ ﻣﻼﺋﻣﺔ ﻟﻠﻐﺭﺽ ﺍﻟﻣﺧﺻﺹ ﻟﻬﺎ‬، ‫ ﺫﺍﺕ ﻧﻭﻋﻳﺔ ﺭﺩﻳﺋﺔ‬، ‫ﺍﻟﺑﺿﺎﻋﺔ ﺍﻟﻣﺳﺗﻠﻣﺔ ﻏﻳﺭ ﻣﻁﺎﺑﻘﺔ ﻟﻠﻣﻭﺍﺻﻔﺎﺕ‬
.‫ﻛﺎﻵﺗﻲ‬
‫ﻲ‬ ‫ﺇﻋﺎﺩﺓ ﺍﻟﺑﺿﺎﻋﺔ‬
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 11 Merchant refused / unable to provide purchased services / goods.
.‫ ﺍﻟﺑﺿﺎﺋﻊ ﺍﻟﻣﺷﺗﺭﺍﺓ‬/ ‫ ﻟﻡ ﻳﺳﺗﻁﻊ ﺗﻭﻓﻳﺭ ﺍﻟﺧﺩﻣﺎﺕ‬/ ‫ﺭﻓﺽ ﺍﻟﺗﺎﺟﺭ‬
12 I have been charged for a transaction that I have already cancelled.
(Cancellation notification is attached).
.(‫ )ﻣﺭﻓﻖ ﺇﺷﻌﺎﺭ ﺍﻹﻟﻐﺎء‬.‫ﻟﻡ ﺍﺣﺗﺳﺎﺏ ﻗﻳﻣﺔ ﻣﻌﺎﻣﻠﺔ ﻋﻠﻰ ﺣﺳﺎﺑﻲ ﻛﻧﺕ ﻗﺩ ﺃﻟﻐﻳﺗﻬﺎ ﺑﺎﻟﻔﻌﻝ‬
13 My Hotel reservation was cancelled on __________ However I have been billed a No-Show Charge.
The Cancellation number is ________________.

14 Others.

15 √ I agree to have my card replaced to facilitate the dispute investigation as and when directed by the Bank.

I declare that above information is true and correct to my knowledge. I understand that I can be held liable for all charges
incurred of dispute raised by me if found invalid. I agree to pay the charges levied by the bank for the same including the
cost incurred for investigation of my claim. The Bank may contact me whenever it requires any further information.

‫ﺍﺣﺗﺳﺎﺑﻬﺎ ﻧﺗﻳﺟﺔ ﻟﻼﻋﺗﺭﺍﺽ ﺍﻟﻣﻘﺩﻡ ﻣﻧﻲ‬/‫ ﻛﻣﺎ ﺃﻋﻠﻡ ﻭﺃﺩﺭﻙ ﺃﻧﻧﻲ ﺃﺗﺣﻣﻝ ﻛﺎﻓﺔ ﺍﻟﺭﺳﻭﻡ ﺍﻟﺗﻲ ﻳﺗﻡ ﺗﻛﺑﺩﻫﺎ‬.‫ﺃﻗﺭ ﺃﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ ﺍﻟﻣﺫﻛﻭﺭﺓ ﺃﻋﻼﻩ ﺻﺣﻳﺣﺔ ﻭﺣﻘﻳﻘﻳﺔ ﺣﺳﺏ ﻋﻠﻣﻲ ﻭﺍﻋﺗﻘﺎﺩﻱ‬
‫ ﻭﻛﺫﻟﻙ ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺩﻓﻊ ﺍﻟﺭﺳﻭﻡ ﺍﻟﺗﻲ ﻳﻔﺭﺿﻬﺎ ﺍﻟﺑﻧﻙ ﺑﺷﺄﻥ ﻫﺫﺍ ﺍﻻﻋﺗﺭﺍﺽ ﺑﻣﺎ ﻓﻲ ﺫﻟﻙ ﺍﻟﻣﺻﺎﺭﻳﻑ ﺍﻟﺗﻲ ﻳﺗﻡ ﺗﻛﺑﺩﻫﺎ ﻧﺗﻳﺟﺔ ﻹﺟﺭﺍء‬.‫ﻭﺫﻟﻙ ﻓﻲ ﺣﺎﻟﺔ ﺛﺑﻭﺕ ﻋﺩﻡ ﺻﺣﺔ ﻫﺫﺍ ﺍﻻﻋﺗﺭﺍﺽ‬
.‫ ﻭﻳﺣﻖ ﻟﻠﺑﻧﻙ ﺍﻻﺗﺻﺎﻝ ﺑﻲ ﻋﻧﺩ ﺍﻟﺣﺎﺟﺔ ﻟﻣﺯﻳﺩ ﻣﻥ ﺍﻟﻣﻌﻠﻭﻣﺎﺕ‬.‫ ﺍﻟﻣﻁﺎﻟﺑﺔ ﺍﻟﻣﻘﺩﻣﺔ ﻣﻧﻲ‬/‫ﺃﻋﻣﺎﻝ ﺍﻟﺑﺣﺙ ﻭﺍﻟﺗﺣﺭﻱ ﺑﺷﺄﻥ ﺍﻟﺩﻋﻭﻯ‬

Home:

Work:
Cardholder signature
Mobile:

eMail:

For Bank Use Only

Important:
Please ensure to attach relevant documentation to support your dispute.
Disputed transaction shall not be entertained without supporting documents.
We may ask in some instances to please provide your Original Cancelled Card and Passport Copies (All pages) to any CBK branch.

Declaration:
I agree to have my card replaced to facilitate the dispute investigation as and when directed by the Bank.

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