BASE BENEFITS 1605

Citi Price Rewind Reference Number General Information Complete Entire Section (Please Print)Credit card number

Cardmember name Daytime telephone number

Cardmember mailing address (city, state and zip code) 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 Credit Account noted above. Statement Credit Check Description of Purchase Manufacturer Model/Serial number Type/Description of item

Date of purchase Purchase price

$

Merchant name

Date of advertisement

Advertised sale price

$

Advertised merchant name

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 void the policy. 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

Program Underwritten by Triton Insurance Company except in New York where it is provided by Citicorp Insurance Services, Inc. (collectively "Provider")

Cardmember mailing address city state and zip code: Statement Credit: Check: Manufacturer: ModelSerial number: TypeDescription of item: Date of purchase: Purchase price: Merchant name: Date of advertisement: Advertised price: Advertised merchant name: A copy of the itemized receipt for the item purchased: A copy of the merchants advertisement with the lower: Date signed: Daytime telephone number:

Cardmember name:

Credit card number: