Claim for purchase with a payment card

Transaction and customer information

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Name (filled in automatically during authentication)*

Last name (filled in automatically during authentication)*

Personal identification code (filled in automatically during authentication)*

Name (filled in automatically during authentication)*

Last name (filled in automatically during authentication)*

Phone number*

Last four digits of card number*

Cardholder’s name, surname*

Transaction date

Sum of transaction

Currency of transaction

Merchant name

Additional information

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