Refund and Reimbursement Form_Interactive_4

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Refund & Reimbursement Form Use this form if you would like to: ã claim a refund on the balance of your myki; OR ã claim a reimbursement on your myki or short term ticket. If you are deaf, or have a hearing or speech impairment, contact us through the National Relay Service: ã TTY users phone 133 677, then ask for 13 6954 (13 myki). ã Speak and listen users phone 1300 555 727, then ask for 13 6954 (13 myki). If you need an interpreter: ã Call the Translating and Interpreting Service (TIS Nation
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  Refund & Reimbursement Form It’s easy to learn more about myki Visit myki.com.au Call 13 6954 (13 myki) If you are deaf, or have a hearing or speech impairment,contact us through the National Relay Service: ã TTY users phone 133 677, then ask for 13 6954 (13 myki).ã Speak and listen users phone 1300 555 727, then ask for13 6954 (13 myki). If you need an interpreter: ã Call the Translating and Interpreting Service (TIS National)on 131 450 and ask for 13 6954 (13 myki).  Use this form if you would like to: ã claim a refund on the balance of your myki; OR ã claim a reimbursement on your myki or short term ticket.  General Information You can use this form to claim a refund OR reimbursement . If you are requesting a full refund, please return your myki  when you submit this form.An administration fee of $9.80 applies to some card servicesincluding requesting a replacement myki or balance transfer.Please visit myki.com.au for details on when the $9.80 fee applies. Refunding remaining balance on a myki You may use this form to apply for a full refund of the balance onyour myki (myki money and/or remaining myki pass days). Partialrefunds are not permitted. Please note, an administration fee of$9.80 may apply.To obtain a full refund, you will be required to return your mykiwhen you submit this form . Your myki will then be cancelled.On-the-spot refunds will not be provided.A cheque for the full refund amount (less the $9.80 administrationfee) will be posted to the address you provide on this form. Forregistered mykis, the cheque will be made out to the accountholder. Account holders should ensure their registration detailsare up to date.Where the refund amount is less than the $9.80 administrationfee, no refund will be processed. If you are a Commuter Club* customer , you can apply for arefund using this form. Refunding the balance on an existing myki, due to changein concession entitlement You can use this form if you have obtained a new mykibecause your travel entitlement has changed. For example,if you previously travelled using a full fare myki and havesince changed to a seniors myki (as you are now eligible forone), you can use this form to obtain a refund on the balanceof your full fare myki. * A Commuter Club is any organisation that purchases yearly travel passeson behalf of the organisation’s members/employees/volunteers. Reimbursements In certain situations, reimbursement for a myki pass or shortterm ticket may be provided.You do not need to submit your myki when applying for a mykipass reimbursement. However, if you are applying for a shortterm ticket reimbursement, you must submit the short termticket with this form. Reasons for reimbursement may include: ã Ticketing equipment faults For short term tickets, the ticket must be includedwith this form. ã Defective short term ticket This is only allowed if a replacement ticket has beenpurchased for travel; both tickets must be submittedwith this form. ã Medical conditions A doctor’s certificate must be provided for each dayof the claim. Conditions apply. ã Special consideration or other reason Please include relevant supporting evidence.You must complete the relevant sections of this form andinclude copies of documentation that supports your applicationfor reimbursement. Please provide as much information aspossible to prove the eligibility of your claim.A cheque for the reimbursement amount, less the administrationfee of $9.80 (if applicable) will be posted out. For a registeredmyki, the cheque will be made out to the account holder. Accountholders should ensure their registration details are up to date.No administration fee applies for ticketing equipmentfaults or defective short term tickets. However, on-the-spotreimbursements will not be provided. You can obtain more myki Refund & Reimbursement Formsby visiting myki.com.au or by calling 13 6954 (13 myki).Post this form to myki MailboxReply Paid 4318MELBOURNE VIC 8060 (No stamp required) If you are requesting a full refund, don’t forget to include yourmyki when you post this form. Or lodge this form at ã The myki discovery centre at Southern Cross Stationã The MetShop (Melbourne Town Hall, corner of Swanstonand Little Collins Streets) Visit myki.com.au for location details.  myki Refund & Reimbursement Form 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 may be the same person. Section A: Customer Details Postal Details Postal details are required for delivery of the cheque or any required correspondence.Title (Mr, Mrs, Miss, Ms, other) Given nameFamily name Contact Details   (Please provide at least one telephone number) Daytime phone number (with area code) Mobile number Preferred Method of Contact (Please choose at least one) X Email X Telephone How to complete this form ã Place a cross X  within the appropriate box when selecting an option.ã Please use BLACK INK and print within the boxes using CAPITAL LETTERS . You can use this form to claim a refund OR reimbursement (choose ONE only). For the difference between refund and reimbursement, please refer to the form notes. ã For refund claims, please complete all sections except Section D and return your myki card with this form; OR ã For reimbursement claims, please complete all sections except Section C. You do not need to submit your myki with this form. StatePostcodeStreet numberUnit numberPO box numberStreet nameSuburb/town FRF-M-001-W Page 1 of 3 Email address (Please complete using CAPITAL LETTERS. If the email address is too long for one row of boxes please make use of the second row provided)  Section B: myki Card DetailsSection C: Claiming a Refund A cheque for the remaining balance (less the administration fee of $9.80 where applicable) will be posted to the address provided in Section A.To request a full refund of the remaining balance on your myki, place a cross in the box below. X Refund the remaining balance on my myki ã FOR REFUND CLAIMS, PLEASE COMPLETE SECTION C AND SKIP SECTION D. REMEMBER TO RETURN YOUR MYKI CARD WITH THIS FORM; OR ã FOR REIMBURSEMENT CLAIMS, SKIP SECTION C AND GO TO SECTION D. YOU DO NOT NEED TO SUBMIT YOUR MYKI WITH THIS FORM. myki card number The 15-digit card number can be found on your myki. FRF-M-001-W Page 2 of 3 To claim a reimbursement, please provide details below in support of your reimbursement request   (including any relevant dates,times, locations, value to be reimbursed, etc). Section D: Claiming a Reimbursement Please place a cross in the box next to the appropriate reason for your reimbursement claim: Location of incident (if applicable) X Medical condition – A doctor’s certificate must be provided for each day of the claim. Applications should be forwarded after themyki pass expires. Conditions apply. Details of claim – If insufficient space, give details on an attachment. X Special consideration/other reason (Please detail below) X Ticketing equipment fault/failure Equipment serial number (where known) X Defective short term ticket – Both defective and replacement tickets must be submitted with this form.Please indicate if the reimbursement is required as a: XX Cheque OR Replacement ticketThe administration fee will be waived if the refund is due to a change in your concession status. If this refund is required as a result of obtaining a new myki due to a change in concession status, please enter your new myki number below. If you are a Commuter Club member you can choose to have your refund sent to your Commuter Club Account Co-ordinator. X  Please send the refund cheque directly to me.   (Go to Section E) X  Please send the refund cheque to my Commuter Club Account Co-ordinator. Name of Commuter Club (employer/organisation) GO TO SECTION E – PLEASE READ AND SIGN THE PRIVACY NOTICE AND DECLARATION. The 15-digit card number can be found on your myki. DMYDYYMY Date of incidentTime of incident : X AM X PM
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