Request for refund of failure ATM transactions

  

If during ATM operation money has not been dispensed but your account has been debited ,please complete the form

ATM Mechine*

                          Note : * is mandatory fields               

ATM Location

  

If other banks ATM Mechine ,Mention Bank Name

  

Card No*

  

Account No(15 Digits)*

  

Name of account holder

  
1. I give details of my following ATM withdrawal transaction

Transaction Date*

   dd/mm/yyyy

Transaction number

  

Amount requested

  

Amount received

 

Amount to be claimed

  
2. I find that the transaction amount / difference amount is not credited to my account at the branch
3. I request you to credit back to my account, the transaction amount/difference amount.
Email address if any   
Phone no   Mobile No

Complaint date

   dd/mm/yyyy

  Comments (Maximum 300 Characters and @#$%^&*+=[]\\\';{}|\":<> symbols wont be accepted in comments)
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