Consolidated Customer Dispute Request Form

Consolidated CustomerDispute Request FormSection 1: InstructionsIn order for us to investigate your dispute:1.Complete sections 2 and 3 in full then select the section applicable to your dispute and complete in full;2.Please complete one form for each disputed transaction if dispute types are different in nature; or3.Should you have multiple disputes relating to the same service, separate forms must be completed for each dispute;4.Please ensure that you read and understand the customer declaration applicable to your dispute;5.Please ensure that all required supporting documentation applicable to your dispute is attached when the dispute is returned to the Bank; and6.Return the completed Document via email to: servicecentre@bidvestbank.co.zaSection 2: Customer DetailsAccount holder nameAccount numberCompany RegistrationNumberID/Passport numberPreferred methodof contactTelephonic//EmailContact numberEmail addressSection 3: Dispute TypeDispute Type(Tick relevant box)A: Request to reverse a debit orderD: Automated Teller Machine (ATM) transaction disputeB: Stop payment requestE: Point-of-Sale (POS) transaction disputeC: Recall EFT instructionF: E-commerce (online purchases) transaction disputeSection 4: Dispute DetailsA. Request to reverse a debit orderRaised via:(Tick relevant box)Transaction dateNAEDO serviceD D /EFT serviceM M / Y Y Y YWithin 40 daysExceeding 40 days (less than 12 months)AmountName of beneficiaryPolicy/Reference numberTrace numberReason(Tick relevant box)30:No authority to debit35:Authorisation cancelled31:Unrecognised initiating party36:Previously stopped via stop payment advice32:Debit in contravention of payers authority33:Payment instruction processed on a datebefore the amount was due34:Not unique transaction referenceCustomer Declaration:I request that the transaction debited against my account, details of which are set out above, be reversed on the basis of me disputing the authority thereof.I hereby confirm that the information supplied is true and correct and acknowledge that if proven otherwise, legal action may be instituted against me.I authorise the Bank to provide a copy of this statement to any person involved in an investigation regarding the dispute, and that I will have no claim against the Bank for anysuch debit order, except if the Bank has acted grossly negligent.Continue on next page.Bidvest Bank Limited (Reg No 2000/006478/06) is a licensed financial services, FSP no 25466, and registered credit provider, NCRCP17.11/20181

B. Stop payment requestRaised via:(Tick relevant box)Transaction dateNAEDO serviceD D /EFT serviceM M / Y Y Y YAmountName of beneficiaryPolicy/Reference numberTrace numberReasonCustomer Declaration:I request that the Bank refuse/return future payments of a specific debit, details of which are set out above, which have previously been collected from my account, on theunderstanding that I have no claim against the Bank if the information is incorrect or in the event of such debit being inadvertently paid by the Bank.I acknowledge that the Bank will not advise the collecting party of the instruction and that it remains my responsibility to contact the user/service provider, with whom Ihave the agreement to request and ensure that the instruction has been cancelled.I hereby confirm that the information supplied by me is true and correct and acknowledge that if proven otherwise, legal action may be instituted against me.C. Recall EFT InstructionTransaction dateD D /M M / Y Y Y YAmountName of beneficiaryBeneficiary accountnumberReference numberReasonCustomer Declaration:I request the Bank to recall the transaction specified above. I acknowledge that reversal attempts are not guaranteed and accept that the Bank relies on the assistance of therecipients Bank to provide resolution.I acknowledge that the account holders affected by the recall may object to it being effected, and if such objections are received, the Bank will not be able to effect therequested reversal and I accept that the objecting payee may be referred to me for resolution of the matter.I further fully indemnify and hold the Bank harmless for any loss, damage or claim, including legal fees on an attorney and own client scale, which may be sustained as a resultof the Bank’s action in effecting the recall.I confirm that the Bank has advised me of the charges (and potential charges) relating to the reversal and I accept these charges and as such authorise the Bank to debit myaccount for said charges irrespective of what the outcome of the recall may be.D. Automated Teller Machine (ATM) Transaction DisputeType of dispute(Tick relevant box)Transaction dateDomesticD D /InternationalM M / Y Y Y YTimeH H:M MLast 4 digits ofcard numberAmount disputedAmount requestedAmount dispensedATM NameATM LocationStatement descriptionContinue on next page.Bidvest Bank Limited (Reg No 2000/006478/06) is a licensed financial services, FSP no 25466, and registered credit provider, NCRCP17.11/20182

Reason(Tick relevant box)I attempted to withdraw funds at the ATM but the ATM did not give me any cash.I attempted to withdraw funds at the ATM and only received a portion of the funds.I attempted to withdraw funds at the ATM and the transaction was duplicated.Transaction was declined, but the funds were debited from my account.I am not disputing the transaction and only require additional information.DetailsPlease provide anyadditional informationif applicableCustomer Declaration:I request the Bank to dispute the ATM transaction of which the details are specified above and refund the value back to my account. I hereby confirm that the informationsupplied herein and all other references have been “true and correct”.I acknowledge that certain resolution time frames apply to my request and may vary depending on the nature of the dispute and that these time frames are governed by theInterBank and Card Association Rules and are most often dependent on the Bank liaising with the other financial institutions to investigate the dispute and refund the valuedisputed.I agree that the Bank may request from me, at any time during the dispute investigation, any additional information or documents which would assist or are required tocomplete the investigation.I further acknowledge that due to such request, additional investigation time may be required, which could therefore result in a delay in the original resolution time framecommunicated to me.I am aware that the dispute may be refuse, if following investigation the transaction is found to be genuine or it has been determined that an error did not occur, in which case,I have the right to request in writing copies of the ATM records and other documents upon which the outcome was based,I acknowledge that the Bank has 30 business days to supply the documents requested by me and should the documents prove to irrevocably substantiate the outcome, I willhave no further dispute with the Bank and will address the dispute directly with the Bank where the ATM is held.I further agree that should the dispute be refused as stated above, the Bank reserves the right to recover any costs it may have incurred as a result of the dispute from me andas such I authorise the Bank to debit such fees from my account.E. Point of Sale (POS) Transaction DisputeType of dispute(Tick relevant box)Transaction dateDomesticD D /InternationalM M / Y Y Y YTimeH H:M MLast 4 digits ofcard numberAmount disputedMerchant NameMerchant LocationStatement descriptionReason(Tick relevant box)I am not disputing the transaction and only require additional information (Copy request)Transaction was declined, but the funds were debited from my account.Transaction was debited more than once.Services not provided or merchandise not received.Credit/Merchant refund not processed.Paid by other means (attach proof).Not as described or defective merchandise and goods returned.The amount debited from my account is different from the purchase value.Transaction was cancelled by merchant, but funds were debited.Hotel/vehicle pre-authorisation settled in error.Continue on next page.Bidvest Bank Limited (Reg No 2000/006478/06) is a licensed financial services, FSP no 25466, and registered credit provider, NCRCP17.11/20183

Please provide anyadditional informationif applicableCustomer Declaration:I request the Bank to dispute the POS Transaction of which the details of the dispute are specified above and hereby confirm that information supplied above is true.I am aware that all payments made to a merchant for any transaction where my card has been used as a payment instrument, are final and irreversible and the Bank is unableto reverse or stop any such payment. I acknowledge that the Bank will however dispute the transaction on my behalf with the merchant’s bankers.I/We acknowledge that resolution time frames will apply which may vary depending on the nature of the dispute, and how the transaction was processed and that such timeframes are governed by the InterBank and Card Association rules and is most often dependent on the Bank liaising with the Merchant’s bankers to investigate and resolvethe dispute.I agree that the Bank may request from me, at any time during the dispute investigation, any additional information or documents which could assist or are required tocomplete the investigation.I further acknowledge that due to such requests, additional investigation time may be required, which could therefore result in a delay in the original resolution time framecommunicated to me.I agree that I will make all necessary efforts to comply with any such request for me to provide additional information or documentation required by the Bank as evidence tosubstantiate my claim. Failure to do so may result in a rebuttal of my dispute.I am aware that should the investigation prove that the transaction is correct, the merchant denied the refund or it has been determined that an error did not occur, the disputewill be successful, in which case I have the right to request, in writing, copies of all evidentiary documents upon which the outcome was based.I acknowledge that the Bank has 30 business days to supply documents requested by me. Should the documents prove conclusive, I further acknowledge that I will have nofurther dispute with the Bank and will address the dispute directly with the Merchant.I further agree that should the dispute be refused as stated above, the Bank reserves the right to recover any costs it may have incurred as a result of the dispute, from meand as such I authorise the Bank to debit such fees from my account.F. E-Commerce (online purchases) Transaction DisputeType of dispute(Tick relevant box)DomesticInternationalChannel(Tick relevant box)WebTelephoneTransaction dateD D /M M / Y Y Y YTimeH H:M MLast 4 digits ofcard numberAmount disputedMerchant NameMerchant URLMerchant contact detailsStatement descriptionReason(Tick relevant box)I am not disputing the transaction and only require additional information (Copy request).Transaction was declined, but the funds were debited from my account.Transaction was debited more than once.Services not provided or merchandise not received.Credit/Merchant refund not processed.Paid by other means (attach proof).Not as described or defective merchandise and goods returned.The amount debited from my account is different from the purchase value.Transaction was cancelled by merchant, but funds were debited.I made a hotel/vehicle hire booking, but cancelled the booking.Cancelled recurring transaction.Did you contact themerchant?YesNoIs there documentation?YesNoContinue on next page.Bidvest Bank Limited (Reg No 2000/006478/06) is a licensed financial services, FSP no 25466, and registered credit provider, NCRCP17.11/20184