CARDHOLDER’S STATEMENT OF DISPUTED ITEM

Date : ______________________________________
Cardholder’s Name : ______________________________________
Card Number : ______________________________________

Posting Date Transaction Date Merchant Name Billing Amount

I have examined the transaction(s) above and dispute the item(s) based on the following reasons
(Please check one)

I certify that neither I nor anyone authorized by me participated in the above transaction(s) and
that my card is in my possession at all times.

I engaged in one transaction from the same merchant location, however, I was charged for more
than one transaction that neither I nor anyone else authorized. I certify that my card was in my
possession at the time of the transaction.
(REQUIREMENT: SALES SLIP OF THE VALID TRANSACTION)

Others, please specify:

REMARKS:

I hereby declare that all information indicated above is true and that my dispute will only be
processed upon completion of this form.

SIGNATURE:
__________________________________________
(Owner of the card where the disputed transaction was posted)

NOTE: If cardholder continues to dispute the transaction but transaction was

subsequently proven to be valid, transaction amount plus the fees and other
charges incurred by BPI as a result will be charged to the cardholder.