2)

CLASS
D
Transaction Dispute Form
A. Please write legibly using capital letters only.
B. You must return the completed form no later than 45 days after the transaction date when the disputed
transaction were charged.
C. You can submit the completed form to any of the following:
 Email: customercare@mail.landbank.com
 Fax to: (02)528-8408
 Mail to Customer Care , LANDBANK PLAZA 1598 M.H. Del Pilar cor. Dr. J. Quintos St. Malate, Manila
1004
 LandBank Branch
D. *For details in dispute, please provide a copy of the following:
 Statement where the transaction appears – indicate the transaction(s) being disputed as well as the
last authorized transaction performed on the card
 Transaction Receipt (e.g., EFTPOS receipt, ATM receipt, payment receipt or sales voucher)
 Any documentation which may support your claim
ACCOUNT HOLDER DETAILS
Surname :
First name :
Middle name :
Phone number:
Account number:
Name of cardholder, if different to account holder:
TRANSACTION DISPUTE (Complete details where known)
Date: 12/20/24 Time: 12:10 AM Amount: 1582.00
Transaction Type
ATM  POS  Online  Mail Order Tel. Order  VMT 
 Non - Dispensed  Account Debited but no goods received VPP 
 Partial Dispensed  Account not Debited but goods received
 Over Dispensed  Twice Debited/Duplicate processing Bank:
 Unauthorized  Over Debit
Withdrawal  Under Debit
 Card Retained /  *Paid by other means (attach proof of payment)
Captured  *Cancelled Transaction: Date cancelled/returned 1 2 / 2 0 / 2 / 45 s
 Others 4 day
Date merchandise/service was expected/received /
Bank/Location:  *Merchandise/Service not Received: Expected date/time of
delivery: / Location:
Description:
 *Defective/Not as described: Date received/returned /
Explanation of quality related issue:
 Credit not processed (attach copy of credit transaction receipt)
 Others/Unauthorized (Lost/Stolen/Counterfeit)
Pls specify
 Request for copy
Bank/Merchant:
*Pls. provide required additional details on the next page.

DETAILS IN DISPUTE
Give details of why the transaction is being disputed or what aspect is being disputed. Specify any
relevant surrounding circumstances and steps taken to ensure the security of the Card and PIN/CVV.
nag order ako mali yung inorder ko pinalitan ko ng item tapos nung
nerefund ko na sabe narefund na daw sa pero hindi pa kase wala pang
nakecredit sa atm ko na
1582 pesos.
Transaction intercom
Dispute po06262018)
Form (Revised ang inorder ko Page 1 of
2
CLASS
Give details of the last transaction(s) authorized by you using your card.
D
Date: 12/20/24 Amount: 2,115.00
Date: 12/20/24 Amount: 1582. 00
Date: 12/16/24 Amount: 332.12
*Please provide the items stated above (letter D)
LOST/STOLEN/MISUSED CARD AND/OR PIN/CVV
What was lost/stolen/misused? Card  PIN/CVV 
Date lost/stolen/misused: MM/DD/YY Time lost/stolen/misused: HH:MM AM  PM 
Date Reported to LandBank: MM/DD/YY Time Reported to LandBank: HH:MM AM  PM 
Where and how did the breach occur? e.g housebreak in or stolen wallet?
Did anyone else have access to your card or did (Please explain briefly how this happened)
you disclose your PIN/CVV to anyone?
Yes  No 
Did you record your PIN/CVV? (Please explain briefly how and where was the
Yes  No  record kept)
Was your card signed? Yes  No 
SIGNATURE
 I confirm that I have not authorized any transaction being disputed as “not authorized” in this
form; or are aware that any amount disputed in this form is in fact a valid charge.
 I confirm that I have not kept in any way a permanent record of the PIN for this card, other than
as disclosed in this form; and have disclosed the PIN for this card to anyone, other than as disclosed
in this form.
 I consent to LandBank providing relevant third parties with copies of this form and supporting
documents as part of the activities required to investigate and resolve this dispute. I understand that
this may include personal information contained in such documents.
 I have read this statement in its entirety and attest that the information provided on this
statement is true and correct.
 I confirm that I have exerted or attempted to resolve the dispute with the merchant or the
merchant’s liquidator, if applicable.
*Date: *Explanation why the dispute is not resolved with the merchant:
 I authorize LBP to debit from the account all applicable fees and charges arising from processing
of this complaint.
12/27/2024
DHANELLA C. CARBONEL MM/DD/YY
Customer/Primary Cardholder Signature over Printed name Date
Transaction Dispute Form (Revised 06262018) Page 2 of

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CLASS

*Pls. provide required additional details on the next page.

Was your card signed? Yes  No 

Transaction Dispute Form (Revised 06262018) Page 2 of

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