龙卡信用卡疑义交易声明（Declaration）
卡号CARD NO: 姓名ACC NAME：
交易日期TRANS.DA TE 商户名称MERCHANT NAME 金额TRANS AMOUNT
本人对上述交易做出以下投诉: I dispute the above transaction(s) for the following reason(s). Please investigate the matter:
1、本人从未授权上述交易,也未授权他人参与交易；
I have neither authorized nor participated in these transactions.
2、发现欺诈交易后已关闭账户；是Yes（）否No（）
Closed the account after finding fraudulent transaction(s).
3、本人向银行报告欺诈交易的日期、时间、方式；。

I informed fraudulent transaction(s) to the bank in ___(way), at____(time), on ____( date)
4、本人向公安机关报案；I have reported to the Public Security Bureau(PSB).
是Yes（）公安机关已受理，描述报案的日期、时间、受理案件的具体机关、案件号并提供公安机关出具的证明；The PSB has accepted the case. Describing the date、time、specific organs, case number and providing the certification(s) by PSB;。

是Yes（）公安机关不受理，描述不受理的原因；The PSB rejected the case. Explain the reasons of rejection;。

否No（）如未报案，说明未报案的原因; If not reported, please explain the specific reasons;。

5、其他。

Others.
备注Comments: 。

本人声明以上所言一切属实。

如有不实，愿负一切法律责任，并同意建设银行向中国银联提供持卡人姓名、申领卡片的身份证件名称及号码，用于欺诈交易调查。

愿意承担因调查而引发的相关查询费用。

（普通商户单据调阅费USD5.00或RMB10.00）。

I guarantee the truthfulness and validity of the above mentioned content. Otherwise, I will undertake all legal responsibilities. Also, I authorize China Construction Bank to provide my name、my ID information to China Union Pay for investigating the fraudulent transaction(s). I’m willing to pay all the expenses of related queries.(retrieval request fee is USD5.00 or RMB10.00)
签署Signature:____________________( 签字式样须与申请表相符Corresponding with the application form): 日期Date:。