PH Yes No No No Yes Yes

CARDHOLDER DISPUTE FORM

The Hongkong and Shanghai Banking Corporation Limited

HSBC Centre 3058 Fifth Avenue West Bonifacio Global City 1634 Taguig City

Attention: DISPUTES RESOLUTION SERVICES

E-mail: [email protected]

Following Visa/Mastercard dispute procedures, please allow us up to 60 calendar days (from the date we received your
complete dispute form and supporting documents) to process your dispute. In case your dispute needs to go through
arbitration, please allow more time for processing. Once our review is completed, we’ll send you the result through your
contact details.

THIS FORM MUST BE RECEIVED WITHIN 60 CALENDAR DAYS FROM TRANSACTION DATE.
You don’t need to print this form. Just fill it out, upload the supporting documents and sign electronically.
Here’s how:

1. Fill out the fields with a red asterisk.

Make sure to fill out the form completely - from top to bottom, as your next required
fields will depend on the Dispute Reason you choose.

2. Need to send more supporting documents?

Simply click on the “Any other document to support your dispute claim” box for the
upload field to appear. Once uploaded, no need to print these.

3. Review your form.

Check if all required fields are completed.

4. Sign electronically.
Click on the Signature box and follow the instructions to sign. You can either type your
name or draw your signature.

5. Finalize
Click the “Click to Sign” blue button then type your e-mail address. A copy of the form
and a confirmation will be sent to the e-mail address you provide.

This form and supporting documents are needed to process your dispute in accordance with the chargeback conditions of
Visa and Mastercard. If we don’t receive this form and supporting documents within the given timeframe, we’ll assume
that you accept the transaction as valid and no longer intend to file a dispute.

For more general information on how we process and safeguard your personal data, please refer to our Privacy
Statement | Privacy and Security - HSBC PH.
The Hongkong and Shanghai Banking Corporation Limited
HSBC Centre 3058 Fifth Avenue West Bonifacio Global City 1634 Taguig City

Credit / Debit Card – Dispute Declaration Web Form

1. Customer Details
Cardholder's Name :

Is the disputed transaction on your Debit or Credit card : Debit Card Credit Card
Please select card type : Mastercard Visa

Card No. :
2. Transaction Details

Transaction Transaction in Original Currency Billed Amount

Merchant’s Name
Date Currency Amount Currency Amount

Note: If you have more than 10 transactions with the same dispute reason, you can attach instead a copy of your credit card
statement highlighting these transactions.

3. Dispute Reason
Note: Choose one dispute reason, then click “Next required field” on the top right of the screen
I was charged for the same transaction more than once on the same card (eg. duplicate transaction posted or billed)
I paid for the transaction by other means (eg. paid transaction using cash, check, other credit card)
I was billed wrongly due to (eg. incorrect amount and/or currency billed)
I am expecting a refund for the transaction and have (eg. no /
incomplete credit received from merchant on promised date)
I have an issue with the that I purchased.(eg. goods or services not received, not as described,
defective or counterfeit)
I am being charged on a recurring basis for service/subscription that I cancelled or not agreed to (eg. cancelled
recurring transaction, subscription or membership)
I did not authorise the transaction (eg. unauthorized or unrecognized transaction posted or billed)
I have an issue with the ATM cash withdrawal transaction (eg. not dispensed, incomplete / incorrectly dispensed,
duplicate posting of cash withdrawal)
Other reasons (eg. foreign currency exchange/loss, etc.)

4. Dispute Details
Have you tried to contact the merchant to resolve the issue? Yes No

I tried to resolve the issue with the merchant via

I have paid for the goods / service by

I was billed in the currency , but I should have been billed in

Is the service provider still operating? Yes No

Have you attempted to claim a refund from the liquidator1? Yes No

The goods / service was The expected delivery date was

The goods / service was delivered on but not acceptable as it was

The goods was returned on and the merchant had the return of goods

The goods was not returned (please specify reason for not returning):

Description of expected goods / service (e.g. brand, model, quantity, destination, mode of travel, etc – as applicable):

Description of why the goods / service was not acceptable:

The service / subscription was cancelled on

The merchant was unable to fulfil the service / subscription. Please specify reason and the remaining session /
duration:

Is the transaction related to additional charges by travel or lodging or known company? Yes No

Are you or your supplementary in possession of the card at the date and time of disputed transaction? Yes No

I have reported to the Bank to block the card on

Note: If your card is not blocked and replaced, it will result in your dispute review being delayed and impact future

potential liability. For assistance, please call HSBC's Customer Service at (02) 8858-0000 or (02) 7976-8000. For

Premier, call (02) 8858-0800 or (02) 7976-8080. For corporate cards, call (02) 8672-6478.

Cash was

I was charged more than once for the same withdrawal

Please provide detailed reason for the dispute:

Please provide any other relevant information related to the dispute:

5. Documentation
Copy of

Copy of
Proof of credit/void receipt or confirmation of refund issued by merchant
Proof of return and/or cancellation of goods / service
Merchant’s return or cancellation or refund policy agreed at the point of sale
Copy of correspondence with the merchant to resolve dispute
Evidence that goods / service was counterfeit or not as described (e.g. picture of goods, document from neutral
qualified merchant in similar business certifying goods was counterfeit, etc)
Evidence that the service provider has ceased operations
Copy of correspondence with the liquidator1
Any other document to support your dispute claim (e.g. Merchant’s cancellation policy, original sale slip)

1Aliquidator refers to an officer who is specially appointed to wind up the affairs of a company when the company is closing—typically when the
company is going bankrupt. Assets of a company are sold by the liquidator and the resulting funds are used to pay off the company's debts.

6. Declaration

Once we receive your completed Dispute Form and supporting documents, we will post a
temporary chargeback credit adjustment on your account within 7 to 10 banking days, so that you won’t need
to pay for the disputed transaction/s while the investigation is ongoing. If you do not submit the complete
documents, we will not post a temporary chargeback credit adjustment and the transaction will remain
outstanding in your Statement of Account, and will be part of your Minimum Amount Due computation. If you
are deemed liable after the investigation period, then we will reverse the temporary chargeback credit
adjustment and you will be billed for the transaction/s in your next statement of account.

For Debit Cards:

In case of a disputed transaction due to a counterfeit card*, additional documents may be requested from you
to assist in the investigation (ie. copy of passport). A temporary refund may be credited to the Account linked to
the Debit Card subject to the Bank’s discretion, upon the Cardholder’s complete submission of documents and the
Bank’s review of the dispute. In the event that the account holder is found liable after the investigation, you agree to
release the temporary refund, or pay back the equivalent amount in case the temporary refund is no longer in the
Account. You agree to discharge the Bank of any and all claims, demands, causes of action, damages, costs,
expenses, attorney’s fees, and obligations of any nature whatsoever, known or unknown, in law or in equity,
arising from and related to all and any suspected fraudulent debit transactions conducted through the Account on
the date of disputed transaction.

*Counterfeit card is an imitation or falsification of a genuine magstripe card or EMV chip card with track
data copied from a hybrid EMV card.

I hereby declare that all information provided in this dispute form are true and that the attachments are genuine
and valid. I understand that the resolution of the dispute is subject to the timeliness and validity of the
submission, applicable guidelines of card networks and result of the investigation, and HSBC does not make any
guarantee that my transaction will be reversed or cancelled. Terms & Conditions of the HSBC Credit Card and
Terms & Conditions of the HSBC Debit Card shall also apply. I further confirm that any electronic signatures
appearing hereunder are the same as handwritten signatures for the purposes of validity, enforceability, and
admissibility. I hereby agree to indemnify and hold harmless HSBC (including its successors and assigns) against
all actions, claims, and damages of whatever nature which may result in connection with HSBC’s reliance on the
information contained herein and my signature, handwritten or electronic, below.

Note: Affix your e-signature by typing your name or drawing using your mouse

Signature