Please keep a copy of this completed form and original documentation.
The signed form must be sent by mail to the address indicated or emailed to
If acknowledgement of your request is not received within 10 business days, please call Travel Money on 1300 660 700.
To: 2067 Operations Processing Centre, Reconciliations and Disputes
PO Box 492, Lidcombe NSW 1825
Facsimile number: (02) 8737 3623
Travel Money ATM Shortpay Request for Investigation
Section 1 – Customer details
First name
Last name
Home address
State Postcode
Home telephone number
Business telephone number Mobile number
Customer email
Title Mr
Mrs Miss
Section 2 – Card details (give details of card that initiated the transaction)
Travel Money Card number - Primary
Travel Money card number - Backup
Section 4 – To be completed by customer in their own words
(please print clearly if insufficient space attach a piece of paper with your additional information)
Give details about the problem (attach copies of any transaction receipts, give name and addresses of any witnesses)
I request the Bank to investigate this claim and declare that the details are true and correct to the best of my knowledge. I am
aware that the Bank may provide information to the police to assist in their investigation and resolution of the dispute.
Customer’s signature
Time Date
Section 3 – Details of transaction(s) requiring investigation
(a) A copy of the receipt(s) (if available) are to be attached.
(b) A copy of the online transaction listing from showing the transaction in dispute MUST be attached.
(c) An ATM Shortpay only occurs when all of the following apply:
The cardholder states that they made the transaction requiring investigation
The cardholder did not receive all or some of the cash requested
The account has been debited
Date of
Amount of
Time of
Location/Details of ATM
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
$ $ $ $
CBA Other Bank ATM
Type of ATM (please tick () appropriate box)
Commonwealth Bank of Australia
ABN 48 123 123 124
Australian credit licence 234945
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