UBS AG Flughofstrasse 35 P.O. Box CH-8152 Glattbrugg Tel. 044-828 31 11 Fax 044-828 31 17 Statement Consulting Tel. +41-44-828 35 34 Fax +41-44 828 33 73 firstname.lastname@example.orgTransaction details Credit card number: Date of transaction: Amount: Store:
I hereby confirm that (multiple answers possible) I have not consented to this charge, either verbally or in writing,nor have I signed a receipt for it and I have never received goods or a service. I signed a receipt amounting to (see enclosed copy). but, my account was debited with the amount of
my credit cardwas charged twice for a purchase I made. the credit receipt issued by the store was not credited to my account (see enclosed copy of the credit receipt). the credit receipt issued by the store wasdebited from and not credited to my account (see enclosed copy of the credit receipt). I cancelled the reservation on: The cancellation number is in writing/by telephone (please underline asappropriate). .
I was not at this hotel and nor did I reserve a room. with regard to the charge of I ordered goods/services but never received them. Furthermore, on I contacted the issuer of the invoice Mr/Msin writing/by telephone (please underline as appropriate), in order to clarify this matter (see enclosed documentation.) Detailed description of the goods/service: I chose an alternative means ofpayment (see enclosed proof of payment). Furthermore, on I contacted Mr/Ms , the issuer of the invoice, in writing/by telephone (please underline as appropriate) to clarify this matter (see encloseddocuments). I do not accept the exchange rate difference of consent to the respective charge. I already cancelled the subscription. The cancellation was made on cancellation). as I gave neither my writtennor verbal (see enclosed copy of the
I consented to the charge in EUR but was not informed about a direct debit in CHF (see enclosed copy of the receipt). Other reasons:
I confirm that I have...