<p> Citibank® Commercial Cards Cardmember Dispute Form </p><p>NAME: ______DATE: ______ADDRESS LINE 1: ______ADDRESS LINE 2: ______CITY, PROV, POSTAL CODE: ______ACCOUNT NUMBER: ______</p><p>Important: Please provide a copy of all information/forms requested below along with your statement with the disputed transaction(s) checked. This form must be filled out completely and forwarded to the Citibank Disputes Department via fax to 519-642-9780 within 60 days of the disputed charges’ posting date or we may be unable to assist you. </p><p>Please read carefully each of the following descriptions and check the one most appropriate to your particular dispute. If you have any questions, please contact us at 1-888-834-2484 (overseas call collect, 416-369-6399). We will be more than happy to advise you in this matter. </p><p> UNAUTHORIZED TRANSACTION – I did not authorize or sign a sales slip, nor did I authorize anyone else to make this charge. </p><p> DUPLICATE PROCESSING — I have been billed for the same transaction more than once. The transaction date, merchant description and location, original currency, and ticket number (if provided) are identical.</p><p> ADDENDUM DISPUTE – I am disputing a transaction that represents an additional charge from the same merchant where I did authorize a valid transaction (for example, an extra billing from a hotel or car rental). Provide in a separate statement the specific details concerning the dispute, your contact or attempts to contact the merchant, and the result of that contact.</p><p>1 MULTIPLE PROCESSING — I authorized a transaction on ______(date) in the amount of $______at ______(merchant name). I did not authorize the transaction on ______(date) in the amount of 2 $ ______at the same merchant. My card has been in my possession at all times. </p><p>3 1 GOODS OR SERVICES NOT PROVIDED  What was the expected delivery date of the goods or service? ______ If delivery of the goods or service was cancelled, indicate the cancellation date: ______*Enclose on a separate sheet a reasonably specific description of the goods or services not received.</p><p>2 MERCHANDISE RETURNED  Merchandise was returned on ______(date). *Enclose a copy of the postal or courier receipt.  A credit receipt for returned merchandise has not posted to the account. *Enclose a copy of the credit receipt.</p><p>1 TRANSACTION AMOUNT DIFFERS  The amount of this charge has been altered since the time of purchase. The difference of amount is $______. * Enclose a copy of the sales receipt or itemized bill that confirms the amount authorized.</p><p> I paid for this transaction by other means. Provide proof of alternate payment. *Enclose a copy of canceled cheque (front and back), copy of other credit card statement, etc .</p><p> Merchant accepted a voucher from a third party. * Enclose a copy of the voucher, itinerary or receipt of payment.</p><p>3 COPY REQUEST - I recognize this charge, but need a copy of the sales draft for my records.</p><p>4If none of the above reasons apply: Use a separate sheet of paper (signed and dated) to provide a complete description of the dispute, attempts to resolve with the merchant and the outstanding issues. </p><p>Cardmember Signature: ______</p><p>© 2010 Citibank Canada. All rights reserved. ® The Citi and Arc Design and Citibank are registered trademarks of Citigroup Inc. All trademarks used under license.</p>