Global Currency Card Disputed Transaction(S)

Disputed Transaction(s) Form.

The purpose of this form is to create a report of charges that are unauthorised or that you wish to dispute. Please send your Questions? completed form to us via: Fax: Australia 1300 781 289 Call 1300 734 020 in Australia or +61 2 9155 7853 Overseas +61 2 9952 3272 when travelling for 24/7 support. Mail: BankSA Global Currency Service Centre PO Box 3845 RHODES NSW 2138

Part 1 Please complete each item in this section

Name Last 4 digits of your card number

Address Suburb Postcode

Email address Preferred contact number

Please list the transaction(s) you would like to dispute:

Date of transaction Merchant name Amount Currency / /

BankSA Global Currency Card is issued by Cuscal Limited ACN 087 822 455 AFSL 244116 (Cuscal). Cuscal is an authorised deposit taking institution and a member of Visa International and does not take deposits from you. Westpac Banking Corporation is the distributor of the product and is not responsible for and does not guarantee the product or card or your ability to access any prepaid value or the use of the product or card. © BankSA – A Division of Westpac Banking Corporation ABN 33 007 457 141 AFSL and Australian credit licence 233714. BSA06606 0121 Page 1 of 3 Disputed Transaction(s) Form.

Part 2 Please check the one category which best describes your dispute. You can only choose one

I certify I did not make the transaction(s)

I have not authorised the charge(s) listed above to my account.

I did authorise the transaction(s), HOWEVER:

I have not received the merchandise. I was charged twice for a single purchase. The expected delivery date is/was Valid transaction $ / / Date charged / / I have not received the expected services. (Note: You must include a copy of the contract Invalid transaction $ or agreement that details these services.)

The merchandise I received was defective. Date charged / / (Note: You must attempt to return the merchandise to None of the above reasons apply. the merchant before filing this claim and then provide (Please provide a complete description of the problem proof of return and explanation of the defect.) in Part 3.) Reply was:

(Note: You must include copies of any correspondence between you and the merchant.) The amount I authorised is different than the amount that showed up on my card account. (Note: If this is a mail order, you must include a copy of the sales slip or packing invoice.)

Part 3 Provide a detailed explanation of the transaction(s) disputed. Use additional pages as necessary A Why are you disputing the transactions?

B How has the merchant responded?

Part 4 Provide bank account details where funds can be returned Credit funds to account.

BSB Account number

Part 5 Signature and consent I give my consent to have this dispute/claim reviewed by a dispute investigator and understand that I may be asked to provide additional details for this investigation. I understand that incomplete or inaccurate information could result in the decline of my dispute or a correction to my account. Please note that if charges were fraudulently posted to your account (your card or card number was stolen) we will block your current card number.

Cardholder name (print)

Cardholder signature Date ✗ / /