Dispute Form 2018

ATM Dispute Form
In order for us to investigate your dispute:

1. The CARDHOLDER INFORMATION and TRANSACTION DISPUTE DETAILS should be complete and legibly filled-out.
2. Please CHECK ONE category which BEST describes your dispute and enclose all SUPPORTING DOCUMENTS.
3. Please complete one form for each disputed transaction if dispute type is different in nature.
Cardholder Information
Cardholder Name (Last, First, Middle Name)
Ang Jhonny Tan
Card Number Account Number
4895040524824394 008670066217
Branch of Account / Card Issuing Branch/Unit Home Address
867 tomas morato metrofocus commercial
Landline Mobile Number Fax Number Email Address
09453292147
Transaction Dispute Details
Transaction Date Posting Date Transaction Type Total Amount of Dispute Remarks
05-08-21 DM 1579.50
17-08-21 DM 1424.80
27-08-21 DM 1296
NOTE: ALL ADDITIONAL INFORMATION MAY BE WRITTEN AT THE BACK OF THIS FORM
Type of Dispute
Unauthorized Transactions Other Transactions
Unauthorized ATM Withdrawal Undispensed ATM Withdrawal Single transaction but charged for more
than one
Unauthorized ATM Fund Transfer Purchase via POS/ internet but was
unsuccessful/ voided Refund/ credit not processed due to
Unauthorized ATM Bills Payment returned item or cancelled transaction
Paid the transaction/s through with attached document
✔ Unauthorized Point-of-Sale (POS) Transaction
attached receipt/ proof of payment
Unauthorized Online Purchase Transaction/ Card-Not-Present Transaction Void Receipt/ Credit Voucher/
Cash Proof of Return
Unauthorized ATM Prepaid Mobile Reload Transaction Check
Others, please specify:
Another Card
Others
Terms and Conditions

All disputed transactions are subject to investigation. For disputed transaction beyond 60 days from transaction date, please attach a letter indicating reason why the
transactions were not immediately reported to the Bank.
Cardholder’s Signature over Printed Name / Date
Deed of Release and Quitclaim (applicable if unauthorized transaction only)

In the event that BDO, upon merit of its investigation and findings and its commitment to its depositors in general and solely as a sign of goodwill / liberality, is willing to credit
the indicated account for the disputed amount or the equivalent amount based on BDO’s investigation, the Undersigned hereby agrees to receive and accept from BDO, and
shall be deemed to have received and accepted from BDO upon credit to the indicated account the total amount credited as and by way of full and final settlement of the
disputed transaction and any other claims arising from the above-stated incidents.
In consideration of the receipt of the credited amount, the Undersigned hereby expressly and absolutely agrees to indemnify and hereby releases and discharges and by these
presents, does forever discharge BDO, its subsidiaries, affiliates and their respective stockholders, directors, officers, employees, agents, representatives, assigns and
successors, from any and all manner of action or actions, cause or causes of action, suits, claims and/or demands whatsoever in law or in equity which the Undersigned, may
now have or in the future claim to have BDO incidental to, or by reason of, or arising out of or in connection with the claim or in any other claims with BDO under the same
circumstances, the intention being to completely and finally release BDO its subsidiaries, affiliates and their respective stockholders, directors, officers, employees, agents,
representatives, assigns and successors, from any and all liabilities arising from or incidental to the Claim contemplated above. If any action, complaint, suit or claim has been
filed by the Undersigned against BDO, its directors, officers employees or authorized representatives with any court, tribunal, office, department, agency, authority or
administrative body arising from or in connection with the Claim, the Undersigned shall cause the withdrawal and/or dismissal with prejudice of such action, complaint, suit or
claim. Any and all taxes arising from the execution and implementation of this Deed and the payment of the subject amount hereunder shall be for the account of and paid for
by the Undersigned.
The Undersigned hereby undertakes to keep and maintain in strict confidentiality the circumstances, events and incidents relating to the claim and the foregoing Deed,
including the terms of this Deed and any discussion made relating to the foregoing. Accordingly, the Undersigned shall not disclose the same (in whole or in part) to any third
party or entity including without limitation, media entities, social networking sites and internet blogs without the prior written consent of BDO. Furthermore, the Undersigned
shall immediately remove or delete at his/her own cost and instance, without need of notice or demand from BDO, any and all past discussions, posts, or other writings relating
to the Claim and the foregoing Deed, that he or she has made in any social networking sites, websites, internet blogs, and any other media sites or other forms of
communication, including those made and/or posted prior to the execution of this Deed. The Undersigned agrees and hereby consents that BDO, at its option, may cause the
deletion or taking down of any such discussions, posts or other writings relating to the Claim and this Deed at the expense of the Undersigned, without need of further act and
deed. The Undersigned undertakes to indemnify BDO for and any all damages that may be sustained by BDO in connection with the failure of the Undersigned to comply with
his/her obligations or agreement under the foregoing Deed.
This Deed of Release and Quitclaim shall be binding upon the Undersigned, his/her heirs, assigns, successors-in-interest, administrator, and legal representatives. The
confidentiality and indemnification undertakings of the Undersigned under this Deed shall be continuing and shall survive the termination or cancellation of this Deed.
The Undersigned hereby affirms that all the information furnished above is true to the best of my knowledge.
Cardholder’s Signature over Printed Name / Date
Notarization
REPUBLIC OF THE PHILIPPINES)
_______________________________) S.S.
BEFORE ME, a Notary Public, for and in the above-mentioned jurisdiction, on this day of _________ at ________, personally appeared the following who have satisfactorily
proven to me their identity through the following Competent Evidence of Identity: _________________________________________________________
and who represented to me that (i) the foregoing Deed of Release and Quitclaim written is integrally complete; (ii) the signature appearing in the foregoing Deed was
voluntarily affixed by the above-mentioned individual for the purposes stated in the foregoing Deed, and who declared that she has executed the foregoing Deed as her free
and voluntary act and deed; and (iii) she avows under penalty of law to the whole truth of the contents of the foregoing Deed. This instrument refers to a Deed of Release and
Quitclaim consisting of one (1) page.
WITNESS MY HAND AND NOTARIAL SEAL on the date and at the place first above-written.
Doc. No. ___; NOTARY PUBLIC
Page No. ___;
Book No. ___;
Series of 201_

Dispute Form 2018

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ATM Dispute Form

In order for us to investigate your dispute:

Terms and Conditions

Cardholder’s Signature over Printed Name / Date

Deed of Release and Quitclaim (applicable if unauthorized transaction only)

Cardholder’s Signature over Printed Name / Date

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