Instructions: DO NOT LEAVE ANY REQUIRED FIELD BLANK.

1. For items in purple, please use the information available in your Statement of Account or Settlement Report.
2. For items in green, please fill out accordingly if applicable: Exact amount for refund (should be equal or less than original currency amount; User ID (ShopeePay) or Account Mobile Number (Pay with Maya, QR Static Transactions, and Gcash).
3. Fields with asterisk (*) are required.

*Merchant Original *Settlement

Local Batch Consumer ID / *Card *Original Exchange *Auth
# *Local Date ID Merchant Name Transaction Type *Merchant Reference Number Currency Currency Other Fee Tax Adjustments IRD *Transaction Reference Number *Acquirer Reference Number *Amount to be Refunded *User ID or Mobile Number *Reasons / Remarks
Time Number Card Number Type Currency Rate Code
(MID) Amount* Amount

- Provide User ID if ShopeePay transaction

Exact amount for refund should be equal or - Provide Mobile Number if Pay with Maya, QR
1 Copy transaction details from settlement report (refer to sample SOA tab)
less than original currency amount Static, and Gcash Transactions

- If card transactions, no need to fill-out

fbddd2f6-5f35-4ec0-ae99-
2 27-SEP-23 07:58:27 230927 100817181 MERCHANT NAME PURCHASE rZl8aXkOWf3aG6J74p3kf64er 105579**6511 PAYMAYA 1600.0000 PHP 0.000000 1600.0000 0.00 0.00 0.00 e161d2 70000003270086194316401 1400.0000
dabec2e161d2
67b91ca1-fb57-4012-bbe0-
3 27-SEP-23 23:20:26 230927 100817181 MERCHANT NAME PURCHASE rpXCiMSItXTs6Pgq0IvtdIts6 106338**1488 PAYMAYA 728.0000 PHP 0.000000 728.0000 0.00 0.00 0.00 609815 70000003270086204692502 728.0000
f4f9e5609815
4

10
Merchant ID 100812345
Business Name BUSINESS NAME
Merchant Name MERCHANT NAME
Bank Account 2367236012345
Bank Name MAYA BANK
Settlement Date Sep 27, 2023

Local Date Local Time Batch Number MID

27-SEP-23 07:58:27 230927 100817181

27-SEP-23 23:20:26 230927 100817181

PAYMAYA Sub- No. of Transactions: Settlement

Total 2 Currency Amt:
No. of Transactions: Settlement
Merchant Sub-Total
2 Currency Amt:
No. of Settlement
Total
Transactions: 2 Currency Amt:
 Copy paste the data from here to the Refund Form

Merchant Name Transaction Type Merchant Reference Number

MERCHANT NAME PURCHASE rZl8aXkOWf3aG6J74p3kf64er

MERCHANT NAME PURCHASE rpXCiMSItXTs6Pgq0IvtdIts6

2328.0000

2328.0000

2328.00
 Statement of Account

Fixed Fee Percentage MDR Gross Deposit

PAYMAYA: 0.00 1.00% N/A 2328.0000
Total: 2328.00

Original
Original
Consumer ID / Card Number Card Type Currency Exchange Rate
Currency
Amount
105579**6511 PAYMAYA 1600.0000 PHP 0.000000
106338**1488 PAYMAYA 728.0000 PHP 0.000000

Tax: 0.00

Tax: 0.00

Tax: 0.00
 MSF
Total: 23.28

Settlement
Other Fee Tax Adjustments Auth Code
Currency Amount
1600.0000 0.00 0.00 0.00 e161d2
728.0000 0.00 0.00 0.00 609815

MSF: 23.2800

Adjustments: 0.0000 MSF: 23.2800

Adjustments: 0.0000 MSF: 23.28

Adjustment Tax Net Settlement
0.00 0.00 2304.72

IRD Transaction Reference Number Acquirer Reference Number

fbddd2f6-5f35-4ec0-ae99-dabec2e161d2 70000003270086194316401
67b91ca1-fb57-4012-bbe0-f4f9e5609815 70000003270086204692502

Net Settlement: 2304.7200

Net Settlement: 2304.7200

Net Settlement: 2304.72