CARDHOLDER’S STATEMENT OF DISPUTED ITEM

Date : ______________________________________
Cardholder’s Name : ______________________________________
Card Number : ______________________________________

Posting Date Transaction Merchant Name Billing Amount

Date

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: 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.