Refund & Reimbursement Form

Transcription

1 Refund & Reimbursement Form Use this form if you would like to: refund the full balance of your myki; OR claim a reimbursement; OR convert your myki pass to myki money. If you are deaf, or have a hearing or speech impairment, contact us through the National Relay Service: TTY users phone , then ask for Speak and listen users (speech-to-speech relay) phone , then ask for For more information about myki Visit ptv.vic.gov.au Call If you need an interpreter: Call the Translating and Interpreting Service (TIS National) on and ask for PTV7541/13

2 General Information Use this form to do one of three things: Refund the balance of your myki Claim a refund when you want your full balance refunded and your myki card cancelled. There are no partial refunds. You can choose to get your refund by cheque, or credit the funds to another myki. If your balance includes a partly used myki pass, you should submit this form as soon as possible. Used myki passes that have expired are not eligible for a refund. Claim a reimbursement A reimbursement is a pay back or compensation. You can either get your reimbursement (i.e. myki money spent and/or myki pass days elapsed) by cheque or you can credit the funds to a myki of your choice. Reasons for reimbursement include medical conditions, system faults and special consideration/ other reasons. Convert your myki pass to myki money Convert your myki pass to myki money when you no longer wish to travel on your myki pass, but want to continue using your myki. You can then use the new myki money credit to travel, or you can use it to buy another myki pass for a different zone or time period. You can convert an unused myki pass OR a partially used myki pass to myki money. Note for students Are you a student pass holder? You MUST return this form to the station that issued your student pass and get your VPT concession card updated. Note to Commuter Club members You can use this form to claim a refund see Section C. For more information about myki Refund & Reimbursement visit ptv.vic.gov.au or call Post this form to myki Mailbox Reply Paid 4318 MELBOURNE VIC 8060 (No stamp required) Please submit your myki with this form if you are requesting a full refund, or if you wish to convert your myki pass to myki money. Do I need to send in my myki card? Refund of balance Claim for reimbursement Convert your myki pass to myki money Yes* No Yes* * If your registered myki has been lost or stolen, you may still submit this form.

3 myki Refund & Reimbursement Form How to complete this form Place a cross X within the appropriate box when selecting an option. Please use BLACK INK and print within the boxes using CAPITAL LETTERS. Please complete the mandatory fields marked with an * below. Section A: Customer Details Please provide details of the cardholder (if your myki is not registered) or the account holder (if your myki is registered). The cardholder is the person who uses the myki to travel, and the account holder is the person to whom the myki is registered. The cardholder and account holder can be the same person. * Title (Mr, Mrs, Miss, Ms, other) * Given name * Family name Postal Details Postal details are required for delivery of the cheque or any required correspondence. Unit number Street name Street number PO box number * Suburb/town * State * Postcode Contact Details (Please provide at least one telephone number) Daytime phone number (with area code) Mobile number address (Please complete using CAPITAL LETTERS.) * Preferred Method of Contact (Please choose at least one) Telephone FRF-M-003-W Page 1 of 4

4 Section B: myki Card Details The 15-digit card number can be found on your myki. I wish to apply for: A full refund of my myki balance > GO TO SECTION C Remember to send in your myki with this form. Is refund due to a change of concession type? A reimbursement of credit > GO TO SECTION D You don t need to send in your myki with this form. My myki pass to be converted to myki money > GO TO SECTION E Remember to send in your myki with this form. IMPORTANT: a myki pass with a remaining value greater than $250 cannot be converted to myki money. If your remaining pass value exceeds $250, you will be issued a cheque refund. You may wish to continue use of your pass until its value drops below $250. PLEASE READ AND SIGN THE PRIVACY NOTICE AND DECLARATION in SECTION E. Section C: Claiming a Refund (myki money credit or cheque) Please credit my refund as: Credit myki money to the myki card below The maximum myki credit amount is $250. If your refund is greater than $250 you will be issued a cheque instead. The 15-digit card number can be found on your myki. Cheque to me For a registered myki, cheques will be sent to the account holder. Cheque to my Commuter Club Account Coordinator Name of Commuter Club (employer/organisation) PLEASE READ AND SIGN THE PRIVACY NOTICE AND DECLARATION in SECTION E. Section D: Claiming a Reimbursement To claim a reimbursement, please provide details below in support of your reimbursement request. Also provide preferred method of reimbursement cheque or myki money credit to a nominated myki card. The maximum myki money credit amount is $250. If your reimbursement is greater than $250 you will be issued a cheque instead. I am claiming a reimbursement due to: Medical condition Claims due to medical condition should be forwarded AFTER your myki pass expires. Attach a medical certificate that covers each day you are claiming. Conditions apply. FRF-M-003-W Page 2 of 4

5 Section D: Claiming a Reimbursement Ticket sale, ticketing equipment or system fault Date of incident (dd/mm/yyyy) Time of incident : AM PM Location of incident (if applicable) Equipment serial number (if applicable and known) Special consideration/other reason (Please detail below) Details of claim If insufficient space, give details on an attachment. Please credit my reimbursement as: Credit myki money to my myki card myki money will be credited to the myki listed in Section B. Credit myki money to another myki card (listed below) The 15-digit card number can be found on your myki. A cheque For a registered myki, cheques will be sent to the account holder. PLEASE READ AND SIGN THE PRIVACY NOTICE AND DECLARATION in SECTION E. FRF-M-003-W Page 3 of 4

6 PLEASE READ AND SIGN THE PRIVACY NOTICE AND DECLARATION in SECTION E. Section E: Privacy Notice and Declaration Public Transport Victoria (PTV) understands and respects your right to privacy and are committed to privacy protection. The Information Privacy Act 2000 (Vic) and PTV s Privacy Policy regulate how we collect and handle your personal information. The account holder or cardholder ( you ) will generally be able to access personal information. If personal information sought by the Public Transport Victoria (PTV) ( we or us ) is not provided, we may not be able to fulfil your request. For further information about privacy and on rights of access to personal information, visit ptv.vic.gov.au or call Unregistered cards: Personal information you provide is collected by or on behalf of the Transport Authorities # for the purpose of fulfilling your request, and will be used and disclosed only for this purpose. Registered cards: Personal information provided by or about you or generated by using the Card is collected by the Public Transport Authorities # to issue and administer the Card and relevant entitlements. Personal information held by the Public Transport Authorities # may be used or disclosed (including to each other) for the operation of the myki ticketing system; to verify entitlement to concession travel; for ticketing enforcement; complaint resolution; in emergencies; otherwise as required or authorised by or under law; or with your consent. A cardholder s personal information may be disclosed to an account holder. # Public Transport Authorities means Public Transport Victoria (PTV), the Department of Transport and any agent, contractor or delegate of PTV or the Department of Transport including public transport operators. I am applying for a refund or reimbursement as stated above. I have read the Privacy Notice. * Signature of applicant or legal guardian/agent for applicants unable to sign please sign * Date (dd/mm/yyyyy) Section F: myki Office Use only Date (dd/mm/yyyyy) Location of lodgement Name of staff member Has VPT student concession card been replaced (if applicable)? Yes No PTV / KAMCO use only Administration Fee (not applicable) Section G: Refund & Reimbursement Customer Receipt Customer, please separate and retain. Enquiries: please call The 15-digit card number can be found on your myki. Date (dd/mm/yyyyy) FRF-M-003-W Page 4 of 4