Cardholder Transaction Dispute Form
Instructions:
In order for us to investigate your dispute:
1. The CUSTOMER INFORMATION and TRANSACTION DISPUTE DETAILS should be complete and legibly filled out.
2. Please check one category which best describes your dispute and enclose all suppor ting documents.
3. Please complete one form for each disputed transaction if dispute types are different in nature.
4. Your duly filled out signed form must reach us through fax or mail within 60 days from posting date.
CUSTOMER INFORMATION
Customer Name (Last, First, M.I)
Card No. Email Address
Tel. No. Mobile No. Fax No.
TRANSACTION DISPUTE DETAILS
Transaction Date Post Date Merchant Name Transaction Amount (Php) Transaction Amount (Foreign)
Unauthorized Transaction Cancelled Membership / Subscription
I did not authorize or par ticipate in the transaction(s) indicated above or I have cancelled the subscription / membership / policy (encircle one)
authorize anyone to engage in the transaction(s) and my card was in my on _____/_____/_____ (dd/mm/yy) yet the charge was billed to my credit card.
possession at the time of purchase. Enclose is a proof of my cancellation with the merchant.
Duplicate Billing Incorrect Amount
I have been billed more than once for the same transaction. I made a transaction amounting to __________. However, I was charged
I authorized only one charge with this merchant for the amount for ___________. I am disputing the difference of ____________.
of _____________ on_____/_____/_____ ( dd/mm/yy). Enclosed is the copy of the sales slip.
Paid by Other Means Undispensed Cash Advance
I used another form of payment for this transaction(s) (cash, check, or other I attempted to withdraw cash thru (name of bank) ___________ ATM located
credit card). Enclosed is a copy of the proof of payment. at ________________________ (Area, City) on _____/_____/_____ (dd/mm/yy),
however no cash was dispensed.Enclosed is a copy of the ATM Slip.
Non-Receipt of Merchandise Refund/Credit Not Processed
I ordered the merchandise on _____/_____/_____ (dd/mm/yy) with an expected I have not received my refund from the merchant. Enclosed is a copy of my
delivery date on _____/_____/_____ (dd/mm/yy). Enclosed is a copy of my credit voucher.
order form.
Defective / Returned / Not as Described Merchandise Others
The item that I purchased did not conform to what was agreed with the Please provide a complete description of the dispute
merchant or was defective. I returned the item(s) last _____/_____/_____ along with your attempted resolution with the merchant. Enclose any
(dd/mm/yy).Enclosed is the proof of return / credit voucher and documentation that may suppor t your claim.
documentation that supports my claim.
TERMS AND CONDITIONS
1. All disputed transactions within 60 days from the posting date will be temporarily credited within 5 days from the receipt of the transaction dispute form.
2. All transaction repor ted beyond 60 days from the posting date will no longer be accommodated and will be considered true, accurate and binding upon you.
3. You will be advised of the final disposition via letter or call out within 90 calendar days from receipt of the transaction dispute form.
4. If the dispute was proven to be invalid, the disputed transaction will be debited back to your statement of account along with the corresponding finance charges due to the
non payment of the disputed transaction(s).
I hereby affirm that the information furnished above is true to the best of my knowledge.
Signature Over Printed Name Date
Customer Service Hotline Numbers: Mailing Address:
American Express International Dollar Cards, Cathay Pacific MasterCard, Visa, JCB, UnionPay, c/o Service Fulfillment Unit
and Peso Platinum Credit Cards: American Express Gold, Green and Blue Credit Cards: 5th floor JMT Corporate Condominium
Tel. No.: 81-417 Tel. No.: 631-8000 27 ADB Ave, Oritgas Center, Pasig City, 1605
Fax No. 857-2430 Fax No. 727-4879 or 727-3924
