CARDHOLDERS STATEMENT OF DISPUTED ITEM

Date : _______________________
Cardholders Name :
Card Number :
Fax Number :
Email Address :

Posting Date Document/Tran Date Merchant Name Billing Amount

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: _________________________________

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.