Uniform Template for lodging of complaints relating to ATM transactions

This is the Uniform template for lodging of ATM Transaction related complaints, across Banks in India.

Simple Tips to make this positive to the Customer

a) Fill the form in 2 copies

b) One copy hand over to the Bank Official

c) On the 2^nd copy, obtain the Bank Official’s acknowledgment

To : The Branch Manager

-------------------------------------------------------------------- (Name of the Bank) *

-------------------------------------------------------------------- (Name of the Branch)

- ------------------------------------------------------------------- (Name of the City)

1. Customer Information :

Name of the Customer :

Account No. :

Debit Card/ATM Card No. :

2. ATM Information :

ATM ID/Location, if ID

is not available :

Name of the ATM Bank :

3. Nature of the Complaints :

a) Complaint relating to Cash withdrawal :

Amount requested for withdrawal : (Rs. )

Amount actually disbursed at ATM : (Rs. )

Amount to the account debited : (Rs. )

Date of transaction : ( / / ) (mm/dd/yy )

Time of transaction : ( )

b) Card Capture by ATM : ( )

c) Other Complaints :

Date: / / Signature of the Card Holder

Contact Tel/Mobile No.

*(Name of the bank branch where the card holder account is maintained, which is linked to the

ATM card)

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