Professional Documents
Culture Documents
P. O. Box 901024
Ft. Worth, TX 76101-2424
Reference Number
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
Sale price
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
Cardmember name
5424181150272834
5104586247
Statement Credit
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
07/13/2015
$ 534.98
tropical_mobile
Item
Sale price
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
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