CASE No.

CARDHOLDER TRANSACTION DISPUTE FORM

Date:______________________________________________
Card No.:_______________________________________________________
Cardholder’s Name:_______________________________________________________
Telephone No.:_______________________________________________________ Fax
No.:_______________________________________________________

TRANSACTION DISPUTE DETAILS:

Posting Transaction Date ATM Branch/ Transaction
Date Merchant Name Amount (USD/PHP)

I have reviewed the transaction/s above and hereby file a dispute for reason/s hereunder:

_____ I certify that I neither participated in nor authorized the above invalid transaction/s and

_____These are lost card usages. My card was reported lost on __________.
_____My card has been in my possession at all times.

_____I have already paid the above transaction/s through:

_____Cash_____Check_____Another card_____Others
Attached is my receipt/proof of payment.

_____I engaged in one transaction, however, I was charged for more than one.

_____I attempted to withdraw cash, but no money was dispensed and/or money was retracted.

_____I attempted to withdraw cash, but only partial amount was dispensed.

_____I return the item/s to merchant on ____________(MMDDYY). Attached is my proof of return.

_____Others, please specify.

___________________________________________________________________________

SIGNATURE:______________________________________Date: ________________