Your First name/Last name

Address

Postal code/ CITY

[Name of your bank]

Address

Postal code/ City

Done in [your city], on [specify the date].

Subject: Dispute of a payment due to bank card theft

Madam, Sir,

I hold a deposit account with your institution, number [indicate your account number]. My bank card was stolen on [indicate the date of the theft]. However, I have noticed that a bank card payment was made afterwards for an amount of [indicate the amount of the transaction]. In accordance with banking regulations, I kindly request that you re-credit this amount to my account as soon as possible.

Please find enclosed a copy of the police report I filed regarding this theft.

While awaiting your reply, please accept, Madam, Sir, the expression of my best regards.

[Your signature]