CARDHOLDER DISPUTE FORM

INSTRUCTIONS:
➢ Kindly accomplish this form, attach required documents and return to the branch where dispute was filed within 3 banking days. Note that these documents
are required before we can process your dispute in accordance with the chargeback conditions of card networks. Failure to provide the required documents
within the specified timeframe, would mean that you accept the transaction as valid and no longer intend to file a dispute.
➢ If disputed transactions are different in nature, please complete one form for each type.
CARDHOLDER INFORMATION:
CARDHOLDER NAME: JESSA LOREN MARIE YASAY CARD NUMBER:
5363 4700 4623 1523
DISPUTED TRANSACTION DETAILS:
TRANSACTION DATE MERCHANT NAME DISPUTED AMOUNT
 Dec 14 2020  LAZADA  500
     
     

I dispute the above transaction(s) due to the reason below (Please tick one box only).
□ UNAUTHORIZED TRANSACTION.
I never participated, authorized the transaction nor disclosed my account details to anyone. I did not sign any slip nor receive any goods/services from the
merchant. (Card used in the disputed transaction must be replaced)
□ I need a copy of the sales slip for my verification as I do not recognize the transaction. I agree that a retrieval fee of Php 300.00 will be charged to my account
in case transaction is valid based on a signed sales slip. (Card used in the disputed transaction must be replaced)
□ DUPLICATE BILLING / PAID BY OTHER MEANS.
My account has been debited more than once for the amount of ____________________ on _____/_____/_____ (DD/MM/YY).
I paid for a transaction using ____________________and was subsequently debited for the same transaction using another form of payment.
DOCUMENT REQUIRED: (Any of the following)
• Bank statement documenting payment to the merchant
• Receipt showing cash as the payment method
□ TRANSACTION AMOUNT DIFFERS / INCORRECT AMOUNT BILLED.
Amount charged was incorrect because the actual transaction amount was ____________________.
DOCUMENT REQUIRED:
• Receipt showing the correct transaction amount.
□ CREDIT NOT PROCESSED.
I received a credit voucher from the merchant last ___14_/___12/__20___ (DD/MM/YY) but no credit refund was processed to date.
X DOCUMENT REQUIRED:
• Documentation to support a credit is due to the cardholder
□ GOODS OR SERVICES NOT PROVIDED.
I did not receive expected goods/services from the merchant last _____/_____/_____ (DD/MM/YY). I asked for a refund from the merchant on
_____/_____/_____ (DD/MM/YY).
DOCUMENT REQUIRED:
• Documents to prove expected date of service/delivery of goods.
• Specific description of the goods/services purchased
□ CANCELLED TRANSACTION / SERVICE.
I have cancelled the transaction with the merchant on _____/_____/_____ (DD/MM/YY).
I have returned the merchandise last _____/_____/_____ (DD/MM/YY) due to ________________________________________ and requested for a refund
from the merchant on _____/_____/_____ (DD/MM/YY).
DOCUMENT REQUIRED: (Any of the following)
• Confirmation of the cancellation provided by the merchant to acknowledge the request issued prior to the billed transaction being disputed
• Acknowledged cancellation letter.
• Proof of return or copy of the credit voucher issued by merchant.
□ GOODS OR SERVICES WERE EITHER NOT AS DESCRIBED OR DEFECTIVE.
Merchandise shipped to me was defective or not the same as ordered so I returned it on _____/_____/_____ (DD/MM/YY). I asked the merchant for a refund
last _____/_____/_____ (DD/MM/YY).
DOCUMENT REQUIRED: (Any of the following)
• Proof of return
• Documentation from an expert or professional about the level of quality or misrepresentation.
• Original receipt, invoice, work order, brochure, contract, or appraisal.
□ OTHERS (Provide detailed explanation)

In making this complaint/dispute, I hereby affirm that my debit card has always been in my possession and has not been reported lost or stolen, and that the information
and attachments in this dispute is true and valid.
I understand that the resolution of my dispute is subject to the timeliness and validity of the submission, applicable guidelines of card networks and result of the
investigation.
Signature: Date:
JESSA LOREN MARIE DORIA YASAY