Customer's Complaint/Request Form for Debit Card or ATM transactions

(Branch where cardholder account is maintained which is linked
to ATM card) Branch

Name

Account No.

Card No.

ATM ID,/Locatuon, if ID is not available

Name of the ATM Bank

Amount requested for withdrawal

Amount actually disbursed at ATM

Amount to the account debited

Date of transaction

Time of transaction

Block / Un-Block Card

PIN-Regeneration

Issue Duplicate Crad

Mobile No. for receiving OTP (One Time Password)

Date

Signature of the Card holder

Contact Tel/Mobile No.