CARDHOLDER DISPUTE FORM

ATM Debit Card/Prepaid Card

Card Number ____ -XXXXXXXX- ____ (First and Last Four Digits ONLY) Date

Cardholder Name

Contact Number Email Address

TRANSACTION FOR DISPUTE

Tran Date Post Date Merchant Name/ Bank ATM Transaction Description Amount

Note: Please accomplish another sheet if the space provided above is insufficient. Total -

DISPUTE TYPE

Please mark with P the applicable dispute type/s box:

Different amount posted on my account and this does not refer to tip (Submit scanned copy of cash receipt or sales slip)

Duplicate Processing (Submit scanned copy of cash receipt or sales slip)

Paid by other means (i.e., through another card or cash) (Submit scanned copy of cash receipt or sales slip)

Cancelled Visa POS or Online Transactions via VISA (Submit any: cancellation letter from merchant, or voided transaction slip, or Certifications
from the Merchant that the merchandise/services were not received/not rendered on a specific date, or returned on MMDDYY)

Credit not processed on returned item/s or REFUND (Submit scanned copy of refund letter from the merchant or credit memo)

Bancnet: Unrecognized/Unauthorized ATM/POS/Online Transaction (Submit scanned copy of visa debit card and valid ID with signature)

VISA: Unrecognized/Unauthorized ATM/POS/Online Transaction (Submit scanned copy of visa debit card and valid ID with signature; Additional
requirement for International ATM Withdrawal/POS: scanned copy of passport - all pages)

Others (please provide detailed explanation):

Card has been reported as lost/stolen?

Yes No My card has always been and remains to be in my possession and has not been reported as lost.

CERTIFICATION

This is to certify that the circumstances I have stated herein are true and correct and the documents I have submitted are authentic or duly issued. That by
sending this form, I understand the following:

✓ Investigation may take up to 60 banking days depending on the dispute type.

✓ Dispute transaction will be processed upon receipt of complete documents (refer to the list of required documents provided in separate sheet).
✓ Applicable Fees such as retrieval fee and card replacement fee shall be applied if disputed transaction/s is/are found to be invalid.

I acknowledge that I have fully read and understood your privacy policy published on your website/ on your webpage:
https://www.eastwestbanker.com/info/ew_privacy.asp. This also affirms my consent to EastWest Bank to process both my personal information and sensitive
personal information for the purpose(s) described in the privacy policy.

Signature over Printed Name of the Cardholder / Date

FOR BANK USE ONLY

Additional requirements/documents for submission of Cardholder Check if submitted Date Received

Documents Received by: Processed by:

Signature over Printed Name/Date Signature over Printed Name/Date

EW Form 18-086 Rev 10/2018 CONFIDENTIAL
Notes:
l If dispute was reported through Customer Service, please send this form via email to csdocs@eastwestbanker.com or fax to (02) 784-5601 to 02.
l EastWest Bank is regulated by the Bangko Sentral ng Pilipinas. For inquiries or complaints, you may contact EastWest Bank through our 24/7 Customer Service Hotline 888-1700.
l Similarly, you may contact the BSP Financial Consumer Protection Department at Tel. No. 708-7087.