Form concerning complaints about a breakdown of a ticket vending machine

The ticket vending machine didn´t give to you any change? The ticket isn´t printed or not even handed out?

We will pay you back 5,- EUR onto a bank giro account or else in the form of tickets and/or stamps. To allow us to pay you back the missing money, we are asking you to fill in the following form:

Applicant
First name/ Family name:
Street/Street number:
Post code and domicile:
Phone number (during the day):
E-Mail (voluntarily):
Information about the ticket vending machine
Number of ticket vending machine:
Location:
Travelling direction:
Information about the incident
The amount of money you chipped in:
Desired ticket:
Did you get the ticket?:
The amount of money you got back:
Reclaimed amount of money:
Date/time of incident:
Remarks:
Information about accounting connection
Please transfer the amount of money onto the following account:
Account holder:
Number of account:
Bank code:
Credit institution:

I´m asking for the pay back of the missing amount of money.

Date:

..

Signature:

---

For internal forwarding (will be filled in by the Rheinbahn):

115.700

->

212.100

Please print the form, sign it and send it together with eventually existing receipts to:
Rheinbahn, Fahrgastbediengeräte, Hansaallee 1, 40549 Düsseldorf, Telefax 0211-582 1570

E-Mail:

rheinbahn@rheinbahn.de