Fill and Sign the 1199seiu Enrollment 2006 Form

Master/Visa Debit Merchant Dispute Resolution Process Form Reason Code 59 – Services Not Rendered Fax Form to: Regulation E – 516 574-7511 RS2 – Service / Goods Paid for by Other Means Description: The merchandise and/or service was paid for by check, cash, credit card or other debit account. Claim Procedure: 1.) Contact ServiceLine at 935-9935 and request assistance with reporting a Master/Visa Debit transaction error. Please obtain the claim (SI) control number from the customer service representative. Control Number is : _____________________________ _____________________ Date Contacted ServiceLine: 2.) Please enter information requested and read the following: Cardholder Information: Chase Checking Account Number: _________________________________________________________________ Chase Master/Visa Debit Card Number: _________________________________________________________________ Name on Card: ______________________________________________________________________ ___________ Transaction Information: Original Purchase: Transaction Date: _____________________________ Transaction Amount: US$________________________ Merchant Name: ___________________________________________________________________________ _____ Merchant Location : ____________________________ Merchant Phone (if available): _____________________ Dispute Information; Note: You must provide proof that the services or goods were paid for by other means, such as copy of the front and back of a canceled check, cash receipt, or other charge card slip. 1) Provide the details of the billing dispute: Note: you must provide a copy of the shipping/delivery agreement if merchandise delivery arrangements were made. According to Federal Regulation, generally Chase has 10 business days to resolve the claim. If at this time it is determined the claim cannot be resolved, and this support documentation is received by the Chase Regulation E department, we must provide a provisional credit while undergoing the investigation. If the support documentation is not received within 10 business days, provisional credit will not be provided. For this type of claim, Chase must refer back to the merchant and it may take up to 90 days to investigate your claim. Please maintain a copy of this form for your records. When opening a new claim the system automatically will generate a letter to you. This letter will contain your Regulation E claim number. Maintain this letter for your files as well. If fax this form along with required support documentation it will not be necessary to provide the requested documentation again. Customer Signature Date Customer Daytime Phone 3. Fax completed form to Reg E Investigations - 516 574-7511 or mail to JP Morgan Chase & Co., Regulation E Investigations, PO Box 1200, Hicksville, NY 11802 If the Investigator has any questions they will contact you. We appreciate your patience while we complete the investigation. Attached Support Document: copy of check (front & back) or copy of cash receipt or other credit/debit card statement and copy of shipping/delivery agreement (if delivery arrangements were made).