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CIS Bayad Center, Inc.

Business Solutions Center, Meralco Complex, Ortigas Avenue, Pasig City

Tel: 6725757, Fax: 6502850 Email Address: bayadcenter@

EDIT/DELETE REQUEST, INCIDENT REPORT & WAIVER FORM

[pic] Altered Check [pic] Staled Check [pic] Wrong Amount [pic] Double Posting

[pic] Cancelled Payment [pic] Unsigned Check [pic] Wrong Biller [pic] System Error

[pic] Cash encoded as Check [pic] Wrong Bank Code [pic] Wrong Bill Presented [pic] No Teller Code

[pic] Check encoded as Cash [pic] Wrong Check Number [pic] Wrong System Date [pic] Unique Constraint

[pic] Post Dated Check [pic] Wrong Amount in [pic] Erroneous Deposit Amount Php ____________________________

Words & Figures [pic] Over Deposit Depository Bank Acct #____________________

[pic] Under Deposit Date of Deposit __________________________

[pic] Others, please specify __________________________________________________________________________________

|Date of Request | |

|Biller | |

|Transaction Date | |

|Account Number | |

|Mode of Payment: [pic] Cash / Amount | |

| [pic] Check / Amount | |

|Check Details (Bank Name & Check No.) | |

|TPA Code | |

|Bayad Center Name | |

|Name of Customer or Representative | |

|Signature of Customer or Representative | |

|Contact Number of Customer or Representative | |

INCIDENT REPORT

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

DATE & REASON FOR REVISION OF EDIT/DELETE REQUEST, INCIDENT REPORT & WAIVER FORM

DATE: ____________________

REASON:

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

WAIVER

I will take full responsibility in case the customer has any dispute in the posted transaction versus the validated amount in the statement of account or payment form. I will not hold Bayad Center liable for the difference, if any.

Requested by: Approved by:

_________________________________ __________________________________

Teller Supervisor/Manager

(Signature over Printed Name) (Signature over Printed Name)

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