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 dierent in nature.
Cardholder Name
Unauthorized ATM Withdrawal
Unauthorized ATM Fund Transfer
Unauthorized ATM Bills Payment
Unauthorized Point-of-Sale (POS) Transaction
Unauthorized Online Purchase Transaction/ Card-Not-Present Transaction
Unauthorized ATM Prepaid Mobile Reload Transaction
Card Number
Branch of Account / Card Issuing Branch/Unit
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.
The Undersigned hereby arms that all the information furnished above is true to the best of my knowledge.
Cardholder’s Signature over Printed Name / Date
Page No. ___;
Book No. ___;
Series of 201_
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, aliates and their respective stockholders, directors, ocers, 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, aliates and their respective stockholders, directors, ocers, 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, ocers employees or authorized representatives with any court, tribunal, oce, 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.
_______________________________) 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 axed 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.
Transaction Date
Unauthorized Transactions Other Transactions
Posting Date Total Amount of DisputeTransaction Type Remarks
Mobile Number
Fax Number Email Address
Home Address
Account Number
(Last, First, Middle Name)
Cardholder Information
Transaction Dispute Details
Type of Dispute
Terms and Conditions
Deed of Release and Quitclaim
(applicable if unauthorized transaction only)
Cardholder’s Signature over Printed Name / Date
Undispensed ATM Withdrawal
Purchase via POS/ internet but was
unsuccessful/ voided
Paid the transaction/s through
attached receipt/ proof of payment
Another Card
Single transaction but charged for more
than one
Refund/ credit not processed due to
returned item or cancelled transaction
with attached document
Others, please specify:
Void Receipt/ Credit Voucher/
Proof of Return