Unauthorized Electronic Transaction: Complaint Registration

Account Number
Name of Complainant
Account Type
     
Home Branch
Mobile Number
E-mail
 
Unauthorised Transaction Amount* (Enter exact amount up to two decimals)
Unauthorised Transaction Reference Number
Unauthorised Response Code
Channel used for Unauthorized Transaction
                 
Unauthorized Transaction Date
Unauthorized Transaction Time
  (H24:MI)
Merchant Name / ATM Location
My Card was in my possession
      
Remarks
   I hereby declare that neither me nor my family member / representative performed / authorized the above transaction(s). Further I hereby declare that I have not shared my login credentials / PIN / password with any other person. I declare that above given information is true and correct to the best of my knowledge. I understand that I can be held liable for all charges incurred if dispute raised by me is found invalid. I agree to pay the charges levied by the bank for the same including the cost incurred for investigation of my claim. I hereby authorize the Bank to deactivate the card on which the unauthorized transaction took place.
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