ATM Withdrawal failed transactions-Complaints to be lodged by Indian Bank Customers only

Please fill the following Form with all the necessary details and hand it over to Branch Manager
To: The Branch Manager,
INDIAN BANK,
_________________________________________________ Name of the Branch *
_________________________________________________ Name of the City
1. Customer Information:
Name of the Customer :
Account No. :
Debit Card / ATM Card No. :
2. ATM Information:
ATM ID/Location, if ID is not available :
Name of the ATM Bank :
3. Nature of the Complaints
a) Complaint relating to Cash withdrawal:
Amount requested for withdrawal : Rs
Amount actually disbursed at ATM : Rs
Amount to the account debited : Rs
Date of transaction : (mm/dd/yy)
Time of transaction :
b) Card Capture by ATM :
c) Other complaints :
Date: / / Signature of the Card Holder
Contact Tel/Mobile No.
*(Name of the bank branch where cardholder account is maintained which is linked to ATM card)