Cardholder Transaction Dispute Form printable pdf download

Cardholder Transaction Dispute Form

Instructions:

In order for us to investigate your dispute:

The

CUSTOMER INFORMATION and TRANSACTION DISPUTE DETAILS should be complete and legibly ﬁlled out.

Please

check one category which best describes your dispute and enclose all suppor ting documents.

Please complete one form for each disputed transaction if dispute types are different in nature.

Y our duly ﬁlled out signed form must reach us through fax or mail within

60 days from posting date.

CUSTOMER INFORMATION

Customer Name (Last, First, M.I)

Card No.

Email Address

T el. No.

Mobile No.

Fax No.

TRANSACTION DISPUTE DETAILS

Transaction Date

Post Date

Merchant Name

Transaction Amount (Php)

Transaction Amount (Foreign)

Unauthorized Transaction

Cancelled Membership / Subscription

I did not authorize or par ticipate in the transaction(s) indicated above or

I have cancelled the subscription / membership / policy (encircle one)

authorize anyone to engage in the transaction(s) and my card was in my

on _____/_____/_____ (dd/mm/yy) yet the charge was billed to my credit card.

Enclose is a proof of my cancellation with the merchant.

possession at the time of purchase.

Duplicate Billing

Incorrect Amount

I have been billed more than once for the same transaction.

I made a transaction amounting to __________. However , I was charged

I authorized only one charge with this merchant for the amount

for ___________. I am disputing the difference of ____________.

Enclosed is the copy of the sales slip.

of _____________ on_____/_____/_____ ( dd/mm/yy).

Paid by Other Means

Undispensed Cash Advance

I attempted to withdraw cash thru (name of bank) ___________ ATM located

I used another form of payment for this transaction(s) (cash, check, or other

at ________________________ (Area, City) on _____/_____/_____ (dd/mm/yy),

credit card). Enclosed is a copy of the proof of payment.

however no cash was dispensed.Enclosed is a copy of the ATM Slip.

Non-Receipt of Merchandise

Refund/Credit Not Processed

I ordered the merchandise on _____/_____/_____ (dd/mm/yy) with an expected

I have not received my refund from the merchant. Enclosed is a copy of my

delivery date on _____/_____/_____ (dd/mm/yy). Enclosed is a copy of my

credit voucher.

order form.

Defective / Returned / Not as Described Merchandise

Others

The item that I purchased did not conform to what was agreed with the

Please provide a complete description of the dispute

merchant or was defective. I returned the item(s) last _____/_____/_____

along with your attempted resolution with the merchant. Enclose any

(dd/mm/yy).Enclosed is the proof of return / credit voucher and

documentation that may suppor t your claim.

documentation that supports my claim.

TERMS AND CONDITIONS

All disputed transactions within 60 days from the posting date will be temporarily credited within 5 days from the receipt of the transaction dispute form.

All transaction repor ted beyond 60 days from the posting date will no longer be accommodated and will be considered true, accurate and binding upon you.

Y ou will be advised of the ﬁnal disposition via letter or call out within 90 calendar days from receipt of the transaction dispute form.

If the dispute was proven to be invalid, the disputed transaction will be debited back to your statement of account along with the corresponding ﬁnance charges due to the

non payment of the disputed transaction(s).

I hereby afﬁrm that the information furnished above is true to the best of my knowledge.

Signature Over Printed Name

Date

Customer Service Hotline Numbers:

Mailing Address:

Amex Dollar Cards, Cathay Paciﬁc & Platinum Credit Cards :

MasterCard, Visa, JCB, UnionPay, AMEX Gold, Green and

c/o Service Fulfillment Unit

Tel. No.: 81-417

Blue Credit Cards:

5th ﬂoor JMT Corporate Condominium