SELECT BUS SERVICE We’re so rry you had a Me troC ard p ...

1 Please use this space to provide details about your problem and transaction amount. SELECT BUS SERVICE We're sorry you had a MetroCard problem. _____ This section for SELECT Bus SERVICE _____ Customers Only Note: You must include your original _____ receipt with this questionnaire and retain a copy for your records. _____. Where did problem occur?: _____. Bus Route/Bus Stop/Cross Street: _____ _____. _____ Please indicate type of machine used: New! _____ MetroCard Fare Collector _____ Machine ID#: File a claim online at for: _____ Coin Fare Collector Lost or Stolen _____ Machine ID#: Reduced Fare MetroCard _____. SELECT Bus SERVICE Incident Date: / / MetroCard Fare Collector _____ m m d d y y MetroCard not returned _____ Incident Time: : am pm from bus farebox We will contact you by mail or phone should Payment Type: (check one) Transfer problem additional information be required. MetroCard Overcharged Single Ride Ticket Reduced Fare MetroCard Certain MetroCard Vending Machine issues Description of the Problem: (Check One) (see our website for complete details).

2 Mail all correspondence to: No Receipt Issued Card was Captured/Not Returned Or complete this claim form Extra Fare Charged Other (Specify Below) so we can process your request. MetroCard Customer Claims Transfer Problem _____. 130 Livingston Street Note: Do not use this form if your 30-Day Note: When using a Metro-North UniTicket, Return Trip Unlimited or 7-Day Express Bus Plus card Brooklyn, NY 11201-9625 Ticket, Block Ticket or General Order Transfer, you do not is lost or stolen and was purchased need to get a receipt prior to boarding. Your ticket is your with a Credit or Debit card. Call us receipt. You must retain your receipt or ticket at all times immediately at Customer SERVICE Customer SERVICE : when boarding and disembarking the bus and show it 1-718-330-1234 or 511 (In NYS Only). 1-718-330-1234 upon request. or 511 (In NY State Only). 372_12 cc . 2 5. We want to resolve the Type of MetroCard Enclosed (check one) MetroCard Vending Machine Please complete this questionnaire immediately and mail Pay-Per-Ride (Regular) Single Ride Ticket (MVM).

3 It to us along with your MetroCard, or MetroCard Vending Transaction: Machine or SELECT Bus SERVICE receipt. Please use ink Unlimited Ride ( SELECT one). and print clearly. 7-Day 30 Day Specify MVM number . 7-Day Express Plus Reduced Fare Important Note for Unlimited Ride Customers: cash debit Amex Discover MC VISA. In order to receive credit for time remaining on your card, Balance remaining $ . Include last 4 digits on debit or credit card . your envelope must be postmarked no later than one day after the problem occurs. Cards that are damaged should Date last used: / / If cash was used: be mailed in. Lost or stolen 7-Day Express Bus Plus or m m d d y y 30-day cards purchased with credit or debit should be Coins inserted. Specify quantity of each type of coin reported immediately by calling 718-330-1234 or 511. Time last used: : am pm inserted: Dollar Coin(s)_____ Quarter(s)_____. Where Purchased (check one).

4 Dimes(s)_____ Nickel(s)_____. 1. Legal Name: Mr. Mrs. Ms. Station (name) _____ Bills inserted: $1 $5 $10 $20 $50.. First Booth number (upper left corner of booth) Total amount of claim $ .. Important Note for MetroCard Vending Machine Neighborhood store _____. 3. Last Store Address_____ (MVM) Customers: If the MetroCard Vendng Machine (MVM) failed to add Street Address MetroCard Vending Machine (MVM). value to your card, you will need to mail in the MetroCard receipt enclosed did not get one used during the transaction. Reduced Fare MetroCard Apt MetroCard Bus MetroCard Van customers are not required to mail their card unless the card is damaged. Other _____. City Date purchased: / / Please ensure that incident date, time ( or m m d d y y ), MVM# and Amount of Claim is provided. State . Zip Code Time Purchased: : am pm . Keep this receipt for your records. Country Description of the Problem (check one) NOTE: The cardholder assumes the risk of loss until.

5 4. See Agent/Invalid Card turnstile or farebox message the MetroCard, MetroCard Vending Machine Receipt or Day Phone SELECT Bus SERVICE (SBS) Receipt is received by the Damaged MetroCard MetroCard purchase/refill problem MetroCard Customer Claims center: Evening Phone Card Expired Free transfer problem 10-digit MetroCard serial number 10-digit MetroCard serial number Extra fares deducted (first set of numbers at upper left-hand corner Please remember to send us your original on back of card under the word expires) Incident date: / / MetroCard Vending Machine or SELECT Bus SERVICE m m d d y y receipt, and keep a copy for yourself. : am pm . SELECT Bus SERVICE Customers ONLY: Incident time: After completing this section (1), go directly to Date mailed the back panel. Skip sections 2,3,4 and 5. m m d d y y