SERVICE REQUEST FORM - DISPUTED DEBIT CARD TRANSACTIONS

Before filling out this form, please contact us on our live chat through the SeaBank Philippines Mobile App or call our 24-hour
Customer Service at (+632) 8424 8050 to report your card transaction dispute.

Please ensure that the information provided in this form corresponds with the details reported on the customer service hotline or
live chat .

1. CUSTOMER INFORMATION

Client Name Email Address

Contact Number Date

Account Number

Card Number

2. TRANSACTION INFORMATION

Transaction Date Merchant Name/ATM Name Transaction Amount Disputed Amount

(DD/MM/YYYY) (Please refer to the transaction history) (PHP) (PHP)

3. DISPUTE CATEGORY (In this section, please select the appropriate dispute category that aligns with the nature of your Please
concern or issue. Refer to the appendix for the list of supporting documents required for each scenario) tick (only
one)

1) Unauthorized Transaction
I did not authorize or participate in the transaction (s) above. My card was (please tick where relevant):
In my possession at the time of the transaction Lost / Stolen on ____________ (DD/MM/YYYY)

2) Duplicate Billing
I was charged more than once for a transaction that I authorized.

3) Incorrect Amount
I made a transaction amounting to _________. However, I was charged for ___________. I am disputing the difference
of ______________.

4) Paid By Other Means

I used another form of payment for this transaction(s) (cash, check, other credit card, others). Please specify:
________________________.

5) Goods Received but Not as Described / Defective

I received goods that were not as described / defective and returned it to the merchant on __________ (DD/MM/YYYY).

6) Non-Receipt of Goods / Services

I have yet to receive the merchandise / service under the said transaction.
The expected delivery / service date was___________(DD/MM/YYYY).

7) Cancellation of Recurring Membership / Subscription

I have notified the merchant to cancel recurring membership/subscription on _______________________
(DD/MM/YYYY), but my account is still being charged.

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 8) Canceled Reservation
I canceled my hotel/airline/car rental/others ________ reservation on ______________ (DD/MM/YYYY) at
________________. The cancellation reference number is _________________.

9) No Cash Dispensed
I attempted to withdraw cash at the ____________ ATM Branch (ATM Bank Operator) located at ______________ (ATM
Location), however no cash was dispensed.

10) Refund / Credit Not Processed

Credit transaction receipt issued but credit not processed/posted to my account or goods returned on
_________________ (DD/MM/YYYY) to the merchant but refund not processed.

11) Others (My disputed transaction is not under any categories above).
Please provide a complete description of the dispute and enclose any documentation that support your claim
________________________________________________________________________________________________
_______________________________________________________________________________________________.

Cardholder's Declaration:

I hereby declare that:

● All information provided above is correct, true and to the best of my knowledge. I understand that SeaBank Philippines, Inc. (A Rural
Bank) has the right to take the necessary action against me for any false claims made on the disputed transactions.
● I hereby authorize SeaBank Philippines, Inc. (A Rural Bank) to investigate and verify the transaction in dispute from whatever
source and whatever means that the Bank considers appropriate.
● I hereby authorize SeaBank Philippines, Inc. (A Rural Bank) to disclose my personal and/or contact information to the merchant
processing bank for the purpose of resolving this dispute.
● I acknowledge that any dispute must be lodged within 60 calendar days from the date of transaction.
● If the transaction is found to be valid, I agree to bear the processing fee of PHP 250 (subject to GST). This amount will be deducted
from my account, along with any other processing charges incurred by the Bank during the investigation.
● I understand and accept that investigation may take up to 120 calendar days or longer if arbitration is required for resolution.
● I understand that SeaBank Philippines, Inc. (A Rural Bank) cannot guarantee the successful recovery of the disputed amount. The
recovery of the disputed amount will be determined by, but is not limited to, the outcome of investigations by the merchant’s banks
and/or rules and regulations of Mastercard.
● I understand that the submission of this form is not regarded as notification of lost card to SeaBank Philippines, Inc. (A Rural Bank) .
● I understand that incomplete forms or forms without supporting documents will not be processed.
● During the course of investigation, I understand that SeaBank Philippines, Inc. (A Rural Bank) will contact me to review the
merchant’s rebuttal of my dispute.
● By submitting this Service Request Form, I knowingly and voluntarily provide my consent for SeaBank Philippines, Inc. (A Rural
Bank) to investigate the matter in dispute, review my bank account records, verify information that I have provided, and disclose
pertinent information, as required, with third parties, which may include details related to my bank account and transactions. I
understand that the purpose for disclosing relevant information of my bank account and transactions to third parties is to facilitate
the investigation of the dispute that I have raised in this form, and that third parties may investigate the matter of the dispute
independently from SeaBank Philippines, Inc. (A Rural Bank). This serves as written confirmation that I am allowing this disclosure
as an exemption to the applicable laws and regulations on the secrecy of bank deposits. I understand that my submission of this
form is not an assurance by SeaBank Philippines, Inc. (A Rural Bank) that the funds in dispute will be refunded or recovered.
● Any document submitted together with this form may be imaged and stored electronically and introduced as evidence in any
proceeding as if original documents. I will not object to the admissibility of such images as evidence in any proceeding on account of
having been stored electronically. This form may be electronically signed. Any electronic signature appearing on this document are
the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

By signing below, I acknowledge that I have read, understood, and knowingly and voluntarily agree to the declarations above.

Cardholder’s Signature: Date:

After contacting customer service via call/live chat, our agent will contact you via email. Please reply to the email with the
completed dispute form and other relevant supporting documents.
(Refer to the Appendix for the full list of documents required from each scenario)
Note: Cardholders should password-protect attachment(s) with this format: DOB in DDMMYYYY+last 4 digits of card number.
(example: 100319801234 denotes date of birth as 10 March 1980, with the last digits of the card number as 1234). Failure to comply
may subject you to the risk of data exposure, and the Bank will not assume liability for any resulting consequences due to
non-compliance.

For more information on how SeaBank Philippines, Inc. (A Rural Bank) treats your personal data, visit
www.seabank.ph/privacy-policy

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 Appendix: Supporting Documents Required for Submission
Note: Ensure that you submit all the required supporting documents as listed. Incomplete submission, lacking any of the necessary
items, will not be accepted unless otherwise specified.

Type of Dispute Conditions Supporting Documents Required

1.) Unauthorized ● The cardholder claimed that neither he, ● N/A

Transaction she, nor anyone authorized by him or
her engaged in the transaction.

2.) Duplicate Billing ● The duplicates must have the same ● Copy of the transaction receipt that you
transaction amount, date, and had authorized.
merchant name as the authorized
transaction.

3.) Incorrect Amount ● The amount/currency on the copy of ● Invoice showing the correct
the receipt must be different from amount/currency agreed by the cardholder.
the amount/currency on the billed
statement, for the same transaction
reference number.

4.) Paid by Other Means ● The cardholder attempted to ● Proof of payments by other means (including
resolve the issue with the cash receipt or other debit card transaction
merchant. receipt)
● The transaction amount and merchant ● (Optional) Proof of attempt to resolve with
must be the same on both the receipt merchant (email/chat/sms correspondences)
and the statement.

5.) Goods Received but ● The cardholder returned the ● Invoice showing description of goods.
Not as Described / goods and attempted to resolve ● Letter from cardholder with explanation
Defective the issue with the merchant to of defects/not as described.
obtain a refund. ● Merchant acknowledgement of returned
goods/invoice showing tracking number from
courier company.
● (Optional) Proof of attempt to resolve with
merchant (email/chat/sms correspondences)

6.) Non-Receipt of ● The cardholder attempted to ● Invoice showing expected goods/services

Goods/ Services resolve the issue with the merchant delivery date and location
to obtain a refund. ● Proof of delivery agreement.
● (Optional) Proof of attempt to resolve with
merchant (email/chat/sms correspondences)
● (Optional) Proof that merchant is unable to
provide goods/services (e.g. news article on
merchant out of business)

7.) Cancellation of ● The cardholder attempted to ● Written cancellation notice given to merchant
Recurring resolve the issue with the prior to billing of dispute transactions
Membership / merchant. ● (Optional) Proof of attempt to resolve with
Subscription ● The cancellation was made before merchant (email/chat/sms correspondences)
the transaction was charged.
● The cancellation must meet the
merchant's cancellation policy.

8.) Cancellation of ● The cardholder attempted to ● Cancellation code issued by merchant and
Reservation resolve the issue with the proof of cancellation
merchant. ● (Optional) Proof of attempt to resolve with
● The cancellation must meet the merchant (email/chat/sms correspondences)
merchant's cancellation policy.

9.) No Cash Dispensed ● NIL ● (Optional) Copy of the ATM transaction slip

10.) Refund / Credit Not ● The refund/credit must meet ● Credit note issued by merchant stating
Processed (not valid for merchant’s terms and conditions card number, date, and refund/credit
verbal agreement by amount.
merchant) ● (Optional) Void transaction
receipt/cancellation code by authorized third
party.