Ex-gratia payment card dispute form Ex-gratia payment card dispute formOnly to be completed by card holder.Those fields marked with a (*) are mandatory, all other fields are optional.Cardholder detailsTitleMrMrsMissMsMstrDrSirLordLadyCaptProfRevFirst NameSurnameDate of birth Day 01020304050607080910111213141516171819202122232425262728293031 Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Year Street AddressStreet AddressStreet AddressCity/TownState/CountyCountryZip/Post CodeTelephoneContact phone (if different)EmailCard detailsCard number Card numberDate of card issue (dd/mm/yyyy)Card currencyPoundsDollarsEurosFlight NumberBooking reference/PNRDispute detailsDate of disputed transaction (dd/mm/yyyy)Dispute detailsATM Swallowed CardATM Failed To Issue MoneyUnknown withdrawal against cardOtherIs the card still in your possession?YesNoValue of disputed transactionIf claim is that ATM failed to issue money please tick here to certify that you did not receive any cash from the ATM.If claim is that ATM failed to issue money please tick here to certify that you did not receive any cash from the ATM.Please tick this box if you did not participate in this transaction.Please tick this box if you did not participate in this transaction.DECLARATION: I am the person to whom the card was issued and all statements made by me in support of my dispute are true to the best of my knowledge and belief. I understand that the information I have provided may be transmitted across national borders and I waive any liability of you and/or the sales affiliate with respect to such transactions. Confirm by ticking here.DECLARATION: I am the person to whom the card was issued and all statements made by me in support of my dispute are true to the best of my knowledge and belief. I understand that the information I have provided may be transmitted across national borders and I waive any liability of you and/or the sales affiliate with respect to such transactions. Confirm by ticking here.NOTICEAnyone who knowingly makes a false statement may be subject to criminal prosecution.British Airways takes the security of personal data very seriously, as explained in our Privacy PolicyPlease note, as with any standard email, any emails containing your personal data sent to or from British Airways will travel in a non-encrypted format.Please do not enter any payment card details into any data fields such as credit / debit card numbers and / or security codes.
