39_19_18 MC Return Card.qxp_MC Return Card 1/18/19 1:22 PM Page 1

Please use this space to provide details about your We’ re so rry you had problem and transaction amount. a Me tr oC ard p rob - We will contact you by mail or phone should This section for Select Bus Service additional information be required. lem. Customers Only (except SBS S79) ______Note: You must include your original * receipt with this questionnaire and retain ______a copy for your records. 6______Where did problem occur?: Bus Route/Bus Stop/Cross Street: ______Please indicate type of machine used: ______MetroCard Fare Collector ______Machine ID#: □□□□□ ______File a claim online at mta.info for: Incident Date: □□ □□ □□ ______m m / d d / y y • Lost or Stolen ______Incident Time: □□: □□ K am K pm Reduced Fare MetroCard ______• Select Bus Service Payment Type: (check one) MetroCard Fare Collector ______K MetroCard K Single Ride Ticket • MetroCard not returned ______K Reduced Fare MetroCard from bus farebox ______(Check One) • Transfer problem DKe scription of the PKro blem: No Receipt Issued Card was Captured/Not Returned • Overcharged K Extra Fare Charged K Other (Specify Below) K Transfer Problem______• Certain MetroCard Vending Machine issues Mail all correspondence to: Note: When using a Metro-North UniTicket, Return Trip Ticket, Block Ticket or General Order Transfer, you do not • Balance Protection Claim* need to get a receipt prior to boarding. Your ticket is your (see our website for complete details) MetroCard Customer Claims receipt. You must retain your receipt or ticket at all times 130 Livingston Street when boarding and disembarking the bus and show it Or complete this claim form upon request. , NY 11201-9625 *so we can process your request. *Note: As fare payment on the SBS S79 is collected Note: Do not use this form if your 30-Day on-board the bus, SBS S79 customers do not use this Unlimited or 7-Day Express Bus Plus card Customer Service: section. Please complete sections 1, 2, 3, 4 and 6. is lost or stolen and was purchased 6 is new label for additional comments section. 1-718-330-1234 with a Credit or Debit card. Call us immediately at Customer Service or 511 ( In NY State Only) M ¯˘¿ 32_19 cc 39_19_18 MC Return Card.qxp_MC Return Card 1/18/19 1:22 PM Page 4

Select Bus Customers We want to resolve the problem... MetroCard Vending Machine Complete this form immediately and mail it to us along with If your problem occured at an SBS Transaction Problem (MVM) your MetroCard, or MetroCard Vending Machine or Select Machine, continue to “SBS” section (back Bus Service receipt. Please use ink and print clearly . panel) and provide information requested. Specify MVM number □□□□ Important Note for Unlimited Ride Customers: (check all that apply) K EBT K Debit K Amex K Discover K MC K VISA MetroCard Enclosed Provide only first six and last four digits on your debit or To receive credit for time remaining on your card, your K Pay-Per-Ride (Regular) K Single Ride Ticket credit card: envelope must be postmarked no later than one day after K Reduced Fare the problem occurs. Cards that are damaged should be Unlimited Ride □□□□□□ X X X X X X □□□□ K 7-Day K 30-Day mailed in. Lost or stolen 7-Day Express Bus Plus or first six K 7-Day Express Bus Plus last four 30-day cards purchased with credit or debit should be Reference # on Receipt: reported immediately by calling 718-330-1234 or 511 or Balance remaining $ □ □□ .□□ 5 online at mta.info . □□□□□□□□□□□□ Important note to Credit/Debit card customers: Most failed 2Date last used: □□ □□ □□ Incident date: □□ □□ □□ m m d d y y credit/debit transactions are resolved automatically within / / m m d d y y 5 – 7 business days. If the appropriate corrections were : / / Time last used: □□ □□ K am K pm Incident time: : K am K pm not made to your account within 5 – 7 business days, □□ □□ please file a claim. Where Purchased (check one) If cash was used: K Station (name ) ______Coins inserted: K $.05 K $.10 K $.15 K $.25 K $1.00 Legal Name : K Mr. K Mrs. K Ms. Bills inserted: K $1 K $5 K $10 K $20 K $50 Booth number □□□□□ □□□□□□□□□□□□□□ (upper left corner of booth) Total amount of claim $ □ □□ .□□ First K Neighborhood stor e ______Store Address______□□□□□□□□□□□□□□ Important Note for MetroCard Vending Machine K MetroCard Vending Machine (MVM) Last 3 (MVM) Customers: K Receipt enclosed K Did not get one If the MetroCard Vendng Machine (MVM) failed to add value □□□□□□□□□□□□□□ to your card, you will need to mail in the MetroCard used Street Address K MetroCard Bus K MetroCard Van during the transaction. Reduced Fare MetroCard 1 customers are not required to mail their card unless the K Othe r ______□□□□ card is damaged. Apt Date purchased: □□ □□ □□ □□□□□□□□□□□□□□ m m d d y y Please ensure that incident date, time (A.M. or P.M.), City / / Time Purchased: □□: □□ K am K pm ¡MVM# and Amount of Claim is provided. □□ □□□□□ □□□□ Keep this receipt for your records. State Zip Code Description of the Problem (check one) – The cardholder assumes the risk of loss until K “See Agent/Invalid Card” turnstile or farebox message NOTE: □□□□□□□□□□□□□□ the MetroCard, MetroCard Vending Machine Receipt or Country K Damaged MetroCard Select Bus Service (SBS) Receipt is received by the K MetroCard purchase/refill problem MetroCard Customer Claims center: □□□ □□□ □□□□ K Card Expired Day Phone – – K Free transfer problem □□□ □□□ □□□□ K Extra fares deducted 10-digit MetroCard serial number Evening Phone 4 – – K Lost or stolen Please remember to send us your original □□□□□□□□□□ MetroCard Vending Machine or Select Bus Service □□ □□ □□ receipt, and keep a copy for yourself. 10-digit MetroCard serial number Incident date: m m d d y y ¡ (first set of numbers at upper left-hand corner / / on back of card under the word expires) □□: □□ K am K pm Date mailed Incident time: m m d d y y