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The document is a Transaction Dispute Form for LANDBANK, requiring completion within 45 days of the disputed transaction. It includes instructions for submission, details required for the dispute, and sections for account holder information and transaction specifics. The dispute involves a refund of PHP 1,582.00 for an incorrect order that has not yet been credited to the account.

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7 views

2)

The document is a Transaction Dispute Form for LANDBANK, requiring completion within 45 days of the disputed transaction. It includes instructions for submission, details required for the dispute, and sections for account holder information and transaction specifics. The dispute involves a refund of PHP 1,582.00 for an incorrect order that has not yet been credited to the account.

Uploaded by

jerick.subad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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LANDBANK
A. Please write legibly using capital letters only.
CLASS D
Transaction Dispute Form
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: [email protected]
 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 : Carbonel
First name : Dhanella
Middle name : Cleofas
Phone number: 09707040537
Account number: 4596000270
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  X Mail Order TTel. 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 4596000270
_________
Withdrawal  Under Debit
 Card Retained /  *Paid by other means (attach proof of payment)
Captured ✓
 *Cancelled Transaction: Date cancelled/returned 1 2 / 2 0 / 2 4 / 45 days
 Others Date merchandise/service was expected/received_____ /_____
 *Merchandise/Service not Received: Expected date/time of
Bank/Location: delivery: ______ /______ Location:________________________
Description: __________________________________________
Rizal, Nueva Ecija
_________________
 *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

Landbank/ shopee
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. intercom po ang inorder ko

Transaction Dispute Form (Revised 06262018) Page 1 of 2


CLASS D
Give details of the last transaction(s) authorized by you using your card.
Date: 12/20/24 Amount: 2,115.00
Date: 12/20/24 Amount: 1582.00
I
Date: I 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 2


Cancellation Request Accepted
Your cancellation request has been approved.
Order 241219995YK7DF has been cancelled.
The refund amount of P1 ,582.00 will be
credited to your Credit/ Debit Card in 5 to 45
working day(s).
12/20/2024 00:10

7:05 0 ~

~ Refund Details G)

Cancellation Cancellation Refunded


Requested Accepted

Refund Completed
~1.582 has been refunded to your Credit/
Debit Card [*2407].
0
11m GEARELEC MALL
GEARELEC DK02 2800mAh Motorcyc ..
2PC-50M intercom xl

~~1.830

Refund Amount Pl,582 0

Refund to Credit / Debit Card [*2407]

Shopee Coins Refundable 1 Coins

Requested by Buyer

Requested at 20-12-2024 00:10

Request ID 24122009DC258U3 COPY

Reason Others

Order Detail

D <J

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