V.

30/11/16

Verification Form/Dispute Page 1/3

Cardholder’s name.................................................................................. Credit Card Number...........................................................................

Card Brand (Visa) (MasterCard) (JCB)
Mobile….....……...…………………… Fax………………....……… E-Mail ………………………………………………...........
Verification/Dispute I hereby certified as a cardholder and agree to obligate according to regulations and all conditions
regarding to this form as followings;
Transaction Total
Merchant Name Merchandise Details/Services
Date Thai Baht Foreign Currency

Reasons for verification/dispute due to the followings;

( ) 1. Request of sales slip or other collection documents
( ) 2. Repeated transaction(s) (only performed once)
( ) 3. Merchandise/services – has been cancelled as of ____/____/_____
( ) 4. No refund was received from merchant
( ) 5. Merchandise or service was not received within _ /_ /_ as stated by merchant. Types of merchandise or services
are....................................Intention to ( ) acquire the merchandise/services ( ) cancellation of merchandise/services
( ) 6. Merchandise/service was paid by ( ) cash ( ) credit card of…………….( ) others please specify………………………………
( ) 7. Unauthorized transaction and request for dispute ……………………………………..........................................................
( ) 8. Incomplete/error through Internet channel or e-commerce
( ) 9. Merchandise or service – damaged/not as agreed/required
( ) Sent the merchandise back to merchant as of ____/____/_____
( ) Cancellation performed as of ____/____/____ Merchandise is now at ( ) Merchant ( ) Cardholder ( ) others please specify
………………………………………………………………………………………………………………………………………………..……….
( ) 10. Incorrect collection amount (The right collection amount is ……………..………......................Baht)
( ) 11. Cash advance transaction via ATM at the amount of …………………. Baht
( ) Cash not received ( ) Partial received at the amount of …………………Baht
( ) 12. Others please identify................................................................................................................................................................. ...........
 V.30/11/16
Page 2/3
Rules and Conditions;
1. Cardholder must fill in details and signed the verification/dispute form, with attached documents according to reasons on page 3
and have the documents submitted to Krungthai Card PLC at Fax 02 123 5190 or Csbackend@ktc.co.th
2. KTC reserves the rights to cancel verified transaction, in case of absence of the verification/dispute form, which includes
required documents within 5 business days, starting from the date of credit card usage protestation. In the case that, KTC
receives the verification/dispute form, SMS shall be sent to inform you within 5 business days. Should you not receive any SMS,
please contact KTC.
3. In the case that cardholder’s request to verify the sales slip, KTC will charge THB 200 for each transaction (Excluded VAT).
4. In the case that cardholder confirms of the dispute to pay, KTC will verify/dispute; if transaction did occur, then cardholder should
be liable for expenses occurred in terms of verification/dispute on such transaction other than the earlier 3s that were mentioned
above (if record showed any request of sales slip previously);
4.1 Chargeback Fee (Excluded VAT)
- THB. 300 /time/transaction if using MasterCard
- THB. 100 /time/transaction if using Visa and JCB
4.2 If the verification is still in process and cardholder wishes to have KTC make a prosecution to arbitrator,
MasterCard/ Visa/JCB through arbitration, which there will be a cost incurred for arbitration committee, which KTC will inform
cardholder beforehand. Moreover, cardholder must submit a request form to confirm an approval of the arbitration process, and
such form shall be submitted back to KTC within 5 business days from the first day cardholder had been informed.
5. Cardholder is obliged for KTC to charge the incurred cost from verified transaction with interests and other cost that might
incurred since the first day of verification/dispute until collection date. Furthermore, reserve for refund including other incurred
expenses as indicated within the form, shall be paid in full to KTC according to regulations/conditions.
6. The period of form verification will be approximately 55 days from the first day of receiving all necessary forms in complete order.
Furthermore, cardholder will be notified from SMS, E-Mail, Fax or letter as stated by cardholder.

….…..../............./.......... ……………………………………………………………
Date Cardholder’s Signature
 V.30/11/16
Page 3/3
Required Documents for Verification/Dispute
Reasons Supplemental Documents with Form
1. Request for sales slip or other documents for proof
Verification / dispute form
of collections
1. Verification / dispute form
2. Repeated Collections
2. Receipt / Sales Slip
1. Verification / dispute form
2. Terms and Conditions
3. Cancellation on merchandise or service (Cardholder
3. Cancellation of Merchandise or Service Documents
must have contacted merchants to resolve issues
4. Communications Report between Customers and Merchants
prior to dispute)
5. Transaction Void Document that stated VOID or Credit Voucher
6. Others
1. Verification / dispute form
4. No refund to credit card as proof from merchants
2. Credit Voucher
(cardholder must contact merchants to resolve
3. Cancellation Conditions from merchants
issues prior to dispute)
4. Sales Slip
1. Verification / dispute form
5. Merchandise/Service not received 2. Order of Merchandise documents
(cardholder must contact merchants to resolve 3. Communications Report between customers and merchants or following
issues prior to dispute) up upon merchandise/service i.e. E-mail, FAX

1. Verification / dispute form

6. Already paid for merchandise or service by cash,
2. Receipt / Sales Slip / Statement
other credit card brand or others
3. Transaction Void Document that stated VOID or Credit Voucher
1. Verification / dispute form
7. Transaction not performed / dispute requested
2. Other related documents
8. Error occurred or incomplete through Internet 1. Verification / dispute form
channel or E-Commerce 2. 2. Details of the merchandise or services
(cardholder must contact merchants to resolve 3. Image of the screen showing incomplete transaction
issues prior to dispute) 4. Communications report between customers and merchants
1. Verification / dispute form
2. Details of the ordered merchandise and merchandise is not as
9. Damaged merchandise/service or not as described
described or damaged (image(s)
and already return merchandise to merchant
packaging/merchandise/warranty/manual or sales slip)
(cardholder must contact merchants to resolve
3. Documents of communication with merchant for cancellation/return of
issues prior to dispute)
merchandise or services
4. Return document to merchandise
1. Verification / dispute form
10. Incorrect collection amount 2. 2. Correct Collection statement i.e. order form / receipt / sales slip /
3. statement
11. Details of ATM withdrawal cash not obtained / 1. Verification / dispute form
obtained partially 2. Receipt / sales slip
1. Verification / dispute form
12. Others issues that were not mentioned above
2. Other related documents