SUBSCRI

BERDI
SPUTEFORM
SUBSCRI
BER’
SGCASHCARDNO:

SUBSCRI
BER’
SGCASHREGI
STEREDMOBI
LENO:

0 9 2 8 6 3 2 1 1 9 8

SUBSCRI
BER’
SFULLNAME

L O U R N A B E L E N T O L O S A

Tr
ansacti
on Mer
chantName( asi
tappear
sint
he Tr
ansact
io Transact
ion
Dat
e st
atement) nAmount Refer
ence

09/
22/
2020 GRABPHTr
anspor
t 483.00 2000452672601

Pl
easesel
ectt
her
easonf
ordi
sput
ingsucht
ransact
ion,
putacheckont
hespacepr
ovi
ded.

Dupl
icat
eChargi
ngIwaschar gedmor et
hanoncef
oratransacti
onIauthor
ized.Pl
ease
encl
osecopyoft
het
ransact
ionrecei
ptwhi
chy
ouhadaut
hor
ized,i
favai
l
abl
e.

Unauthori
zedTr ansacti
onThi str
ansact
ionwasneit
hermadenorauthori
zedbyme/my
supplementar
ycar dhol
der.Thecardwasinmypossessi
onatthet
imeofthetr
ansacti
onand
atalltmes.Pl
i easeencloseacopyoff r
ont&backofthecar
d,andacopyofthetransact
ion
recei
pt,i
favai
lable.

Paidbyothermeans.Ihav ealr
eadypaidforthi
stransact
ionbyothermeansCash,Cheque
andotherCard.Pleaseencloseproofofpaymentbyot hermeans( e.
g.cashrecei
pt,ot
her
credi
tcardtr
ansactionr
eceiptetc.
)Pl
easedescri
bemodeofal t
ernatepayment(e.
g.cash,
cheque)
:___
_____
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_

Incor
rectAmount .Theamountchargedtomyaccounti
sdiff
erentfrom t
heamountt
hatI
hadaut hori
zed.Pl
easeprovidetheamountyouhadaut
hori
zed:_ _
____
____
___
___
__Pl
ease
alsoenclosecopyofthet
ransact
ionr
ecei
ptwhichy
ouhadaut
horized.

Cancell
ed member ship/subscr
ipti
on.Ihav e cancell
ed mysubscr i
pti
on/member
ship on
(date)_
_ _
______
_ .Pl
_ easeenclosecopyofthecancel l
ati
onnot i
ceaddressedtot
hemerchant
withemai l/
fax/postalconfir
mation.Pl
easenot et hatther equestwillnotbeprocessed
unlessthecancellat
ionwasdone15day spr i
ortothesubmi ssiondateofthi
sfor
m.
 MerchandiseDefect
iveorNotasDescr ibed.Goods/servi
cesreceiv
edwer eei
thernotas
descr
ibed,damaged/def
ective,ornotsui
tabl
eforit
sintendedpurpose.Ihav
econtact
edthe
merchanttoresol
vethedisputeondate_____
____
_.

Please att
ach anyrel
evantdocuments suppor
ti
ng yourclai
m.Please pr
ovide a br
ief
descri
pti
on on how goods/
ser
vices wer e not as descr i
bed/def
ecti
ve:
___
______
_____
____
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_ _
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____

Goods/ Ser vi
cesnotr eceived.Goods/ Servi
cesf orthet r
ansacti
on(s)wer enotrecei
veddue
toinabilit
y/unwil
lingnessoft hemer chant.Ihav eattempt edtoresolvethedisputewiththe
merchantand/ ormer chant’
sl i
qui
datoron( dat e)
______
_ _.Goods/Serv
iceswer eexpectedto
bedeliv er
edon( date)_________
_.Pleaseencl oseprooft hatthedisput
ehasbeenaddr essed
tomer chantwi thf ax/postalconfi
rmation.Pleasepr ovideabr i
efdescript
ionoftheexpected
goods/ servi
ces:___ _
___________
_______
_ _
__________
__________
_____
_ _
______
_ _
____
_____
_

ATM wi t
hdr
awal.Ihavetri
edtowithdr
awcashf rom theATM of(nameofBank)___
_ _
___
_at
(l
ocati
on)___
_____
___butcashwasnotdispensed(ATM slipcopyencl
osed)
.Ihaverecei
ved
only( amountandcurrencyofamount)forATM withdrawalbutanamountof(
amountand
curr
encyofamount)wasdebitedfr
om mycar daccount.

Ref und/Creditnotpr ocessed.Creditt

ransactionr ecei
ptissuedbutcr edi
tnot
processed/ postedt omyaccountorgoodsr et urnedon( date)__
_ ___
_______
tomerchantbut
refundnotpr ocessed.Pleaseenclosethecredi ttr
ansactionreceiptand/orencl
oseproof
thatthemer chantr ecei
vedtheretur
nedmer chandi see.
g.RegisteredMai lr
ecei
ptorcouri
er
i
nv oicesignedbyt hemer chantuponreceiptoft hegoods.

Ot
hers(Pl
easeprovi
dedet
ail
edexpl
anat
ionandencl
osenecessar
ydocumentt
osuppor
tthe
di
sput
e–ifappli
cabl
e):

GrabDri
verCancel
l
edt hebooki
ngpaymentwastakenbutnitreturnedonmy bgcashacct.
✔
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CARDHOLDER’
SDECLARATI
ON

Iher
ebydecl
aret
hat
:

 Al
li
nfor
mat
ionpr
ovi
dedabov
eiscor
rect
,tr
ueandt
othebestofmyknowl
edge

 Iher
ebyaut
hor
izeG–Xchange,
Inc.t
oinv
est
igat
e/cor
rectt
het
ransact
ion(
s)i
ndi
sput
e.

 I
fthetransact
ionisfoundtobelegi
ti
mat e,Iagree(
a)tobeart
hesal
esslipretr
iev
alfeeof250
pesosandot herprocessi
ngchargesincurredbytheG–Xchange,I nc.inthecourseoft he
i
nvesti
gati
on,and(b)theG-Xchange,
Inc.hast heri
ghtt
orever
seanytemporarycredi
tgivenin
thi
sregard&levyappli
cabl
efeesandinterestsonthetr
ansact
ionwi
thretr
ospecti
veeffect
.

 Iunderstand t
hat the i nvest
igat
ion may t
ake 180 day
s (
or mor
e i
f pr
e-
ar
bit
rat
ion/ar
bit
rat
ioni
srequi
red)f
orresol
uti
on
  Iunderst
andt hatthesubmi
ssi
onoft
hisf
ormi
snotr
egar
dedasanot
if
icat
ionofl
ostcar
dto
theG-Xchange,Inc.

 Iunderst
and t
hati
ncompl
etef
ormsorf
ormswi
thoutsuppor
ti
ngdocument
swi
l
lnotbe
pr
ocessed

 Duri
ngt hecourseofi nv
esti
gations,Iunderst
andG-Xchange,Inc.wi
l
lcontactmetorevi
ew
merchant’
srebuttalofmydispute.Iunderst
andfai
l
uretoresponsewit
hinspeci
fi
edt
imef
rame
wil
lresul
tinmyt emporarycredi
ttober ev
ersed.

Iagr eeandconsentt ot heG-Xchange,I nc. and/ ortheper mitt

edpar ti
escollecti
ng,andusing( a)
i
nf ormationwhi chmayatanyt i
mebepr ovidedt otheG- Xchange, I
nc.inconnectionwiththi
sform, and
(b)myaccounti nf
ormationtotheextentt hati ti
sr equir
ed,(col
lecti
vel
y,(a)and(b)shallbereferr
edas
“Information”
)f orthe purpose off acil
itating the processing and investi
gation ofthe disputed
transacti
onbyG- Xchange,Inc.and/ort heper mittedparti
es( coll
ecti
vely,t
he“ Purposes”)
.If urt
her
agr eeandconsentt otheG-Xchange,Inc.di sclosi
nganyI nformationtoaper mitt
edpar t
yorsuchot her
par ti
es(i
ncludingCar dSchemessuchasBancNet , VisaandMast erCar
d,andanyr el
evantaut
hority
)for
thePur poses.

Lour
naBel
enATol
osa Sept
ember23,
2020
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Si
gnatureoverPr
int
edName Date

09458447376. Dayl
e_777@yahoo.com
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ContactNumber EmailAddress