Citi Price Rewind

P. O. Box 901024
Ft. Worth, TX 76101-2424

Reference Number

Instructions for Completing Citi Price Rewind Claim

In order for us to process your claim quickly, please read and follow instructions listed below. Please enter one Citi Price Rewind
claim form for each item that you purchased.
1. Please complete this claim form; sign it and either fax it to 1-817-820-5917 or mail to: Citi Price Rewind, P.O. Box 901024, Ft.
Worth, TX 76101-2424 with all required documents NO LATER THAN 180 DAYS from the date of purchase. A delay or denial
of your claim may result if the completed claim form is not received within 180 days from the date of purchase. If you cannot
obtain all of the requested documents within this timeframe, please send the claim form to us anyway. Please allow 15 days after
mailing for processing fully completed claim forms.
2. The following documents are required in order to process your claim form:
A) A copy of the itemized receipt for the item purchased.
B) A copy of the merchant's advertisement with the lower price for the same item by the same manufacturer. The
advertisement must state;

Item

Effective date of sale (within 60 days of purchase)

Sale price

Model number and model year

Authorized dealer or merchant name (in US only)

All documents must be legible

If additional information is required, we will contact you. Please retain a copy of all receipts and documents for your personal
records. We appreciate your business and look forward to serving you in the future. For questions or assistance call 1-855-5697366, Monday through Friday, 9:00 a.m. 11:00 p.m. ET and Saturday, 8:00 a.m. 8:00 p.m. ET.
All pages to this claim form must be returned in order to process this claim.

FRAUD NOTICES
(Note: None of these fraud notices apply to residents of Oregon or New York.)

Except as Indicated Below: "Any person who, with intent to defraud, knowingly submits an
application to or files a claim with an insurance company or other person containing false,
incomplete, misleading or deceptive facts, statements or information may be guilty of insurance
fraud, which is a crime and subjects such person to civil and criminal penalties that can include
fines and confinement in prison."
For Arizona Only: "For your protection Arizona law requires the following statement to appear on the form.
Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal
and civil penalties."
For California Only: "For your protection California law requires the following to appear on this form. Any
person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and
confinement in prison."
For Pennsylvania Only: "Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false
information or conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties."

BASE BENEFITS

1605

Reference Number

Citi Price Rewind

General Information Complete Entire Section (Please Print)
Credit card number

Cardmember name

Daytime telephone number

5424181150272834

Ashish dineshbhai patel

5104586247

Cardmember mailing address (city, state and zip code)

4117 Stevenson blvd, #245, Fremont, California-94538

Please select whether you would like to receive your refund as a credit on your account statement or a check mailed to the
address above. If the refund amount is $25 or less, the payment will be in the form of a statement credit to your Citi

Statement Credit

Credit Account noted above.

Check

Description of Purchase
Manufacturer

Model/Serial number

Type/Description of Item

tropical_mobile

R58G427WB5F

Samsung galaxy s6

Date of purchase

Purchase price

Merchant name

06/12/2015

602.98

tropical_mobile

Date of advertisement

Advertised sale price

Advertised merchant name

07/13/2015

$ 534.98

tropical_mobile

Checklist For Claims Submission

A copy of the itemized receipt for the item purchased

A copy of the merchant's advertisement with the lower

price for the same item by the same manufacturer. The
advertisement must state;

Item

Effective date of sale (within 60 days of purchase)

Sale price

Model number and model year

Authorized dealer or store name (in US only)

Certification
I certify the foregoing statements are true and correct to the best of my knowledge and belief, without evasion or reservation. If in
fact, the furnished information is false, thereby inducing payment of a claim, and the Provider determines that the incorrect
information constitutes an aiding and abetting of the filing of a fraudulent claim, the Provider may furnish the above information to
the appropriate state authorities to be used in its discretion as the basis for action authorized under applicable state law. In
addition, I agree any statements made on this or any other form found to be false, shall give the Provider the right to deny this
claim. If additional information is deemed necessary, the Provider may require you to sign an Authorization to Release
Information which could delay the processing of your claim.
Signature of Cardmember
Date signed

Ashish Dineshbhai Patel

07/13/2015

Program Underwritten by Triton Insurance Company except in New York where it is provided by OneMain Alliance,
LLC (collectively "Provider")

BASE BENEFITS

1605