ATM Debit To Branch Manager Name of the bank ID: 936831
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(ATM Debit transaction Complaint Form) To Branch Manager ................................ ................................ .................. (Name of the bank)* ................................ ................................ ................... (Name of the Branch)* ................................ ................................ ..................... (Name of the city) *(Name of the bank branch where the card holders account is maintained) 1. Customer information Name Account No Debit/ATM Card No 2. ATM Information ATM ID / Location if ID not available Name of the ATM Bank 3 . Nature of Complaint A. Complaint relating to cash withdraw a l Amount of withdraw a l Rs. Amount actually disbursed by ATM Rs. Amount to the account debited Rs. Date of transaction (MM/DD/YY) Time of transaction B. Is Card capture by ATM : - Yes / No C. Other complaints : - Note: * F orm to be submitted to the ATM branch , In case on ‘Non Banking Hours’ handover Form to ATM security Guard . Form duly filled with all required field. • * Copy of ATM Transaction slip/ Merchant Charge Slip (if available) • • • • Signature (Card holder) Date : - • • Contact Tel/Mobile No : -