| Name of the BANK / ATM |
|
Name of Branch / City |
|
| Customer Information |
|
|
| Name of the Customer |
|
Customer Contact Number |
|
| Savings A/c Number |
|
|
|
| Card Type |
Rupay
EMV Card
KCC Debit Card |
|
|
| Card Number |
|
|
|
| ATM Information |
|
|
| ATM Id or Location name |
|
|
|
| Name of the ATM Bank |
|
|
|
| Nature of Complaints |
|
|
| a).Complaint relating to cash Withdrawal |
|
|
| 1.Amount Requested for Withdrawal(Rs.) |
|
4.Date of Transaction |
|
| 2.Amount Actually Disbursed at ATM(Rs.) |
|
5.Time of Transaction |
|
| 3.Amount Debited from the Account(Rs.) |
|
|
|
| b).Card Captured By ATM |
|
|
| c).Fradulant Transaction(s)(Card Blocking Mandatory) |
|
|
| d).Forget PIN(Personal Identification Number) |
|
|
|
| e).PoS(Point of Sale) Related Complaints |
|
|
|
| f).Other Complaints, specify |
|
|
|
|
|
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|
