Union Bank Of India
To: The Branch Manager
_______________________________________________ (Name of the 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.