Cardholder Disclaimer Form printable pdf download

Cardholder Disclaimer Form

AIB Cardholder Disclaimer Form

(For ATM & POS Debit Fraud/Customer Service Chargebacks)

To be completed by cardholder and returned - Debit Fraud, Card Issuing, AIB Bank, Sandyford, Dublin 18

9 3

Cardholder Name :

NSC:

Address:

Account Number:

AIB Debit Card Number:

Reason Disputed

(Please select one option)

Unauthorised Withdrawal

Unauthorised Point of Sale Transaction

Refund Not Processed - (Refund copy voucher MUST be included)

Transaction Amount Differs by €______- (Copy Sales voucher MUST be included)

Duplicate Transaction on _ _ / _ _ / _ _ + _ _ / _ _ /_ _

Transaction processed on mutliple dates _ _ / _ _ / _ _ , _ _ / _ _ / _ _, _ _ / _ _ / _ _

Copy Voucher (Retrieval) Request

Card Details

(Please select Yes or No to each of the following options)

Yes No

Card was stolen at the time the transaction took place

Card was lost at the time the transaction took place

Card has been recently re-ordered but never received - (If YES, Report to Gardai & send on Garda Report)

Card was in your posession at all times

PIN was disclosed to a third party

Card was made available to a third party

Disputed Transaction Details:

(Trans. Date, Trans. Amt & Merchant Name)

Transaction

Transaction Date

Amount

Merchant Name

Allied Irish Banks, plc. Registered Office: Bankcentre, Ballsbridge, Dublin 4. Registered in Ireland. No. 24173.

Allied Irish Banks, p.l.c. is regulated by the Central Bank of Ireland.

Cardholder Disclaimer Form