CARDHOLDER’S STATEMENT OF DISPUTED ITEM

Date : _________________________________________________________
Cardholder’s Name : _________________________________________________________
Compromised 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:
 Please send the accomplished dispute form to bpidispute@bpi.com.ph. You may also follow up by calling
580-0496.
 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.
 Reported disputes can be accommodated within thirty (30) calendar days from the statement date indicated
in the SOA.