LETTER TO BE SUBMITTED BY DEBIT CARDHOLDER FOR DISPUTED POS/INTERNET TRANSACTION/S
From, Date: _________________ _________________________ _________________________ Phone No.: __________________ e-mail id: ___________________________ To, The Branch Manager SyndicateBank Branch __________________ Dear Sir, Ref: My Debit Card No. ________________________ linked to A/c no. ______________________ This is to inform that the following transaction debited in my account on____________ was unsuccessful / has not been carried out by me (strike out whichever not applicable)-
Transaction attempted Through
Name of the Merchant Establishment
Location of Merchant Establishment
POS/Merchant Establishment (ME)
Transaction Details are as follows:
Details
Dispute 1
Dispute 2
Date of Transaction
Amount attempted through Transaction
Amount Disputed
Reason/s for Dispute/s is/are as follows:
Reasons for Dispute
Dispute 1
Dispute 2
A/c Debited but transaction unsuccessful at POS/M E
Single transaction processed more than once at POS
Amount debited in my a/c but transaction not recognized / authorised by me. It may be deemed as a fraudulent transaction.
I request that the transaction may please be verified and suitable action may be initiated to reverse the amount with relevant charges in my Card account. In case the disputed transaction is decided in favour of acquirer as per VISA Dispute Resolution Rules, I hereby authorise you to debit my Card account with principal amount and relevant charges, including charges claimed by the acquirer bank, from the value date of the transaction. I undertake to pay the entire amount in such event.
Name of the Cardholder
Signature of the Cardholder
FOR BANK’S USE ONLY:
Branch Name
Signature Verified By
Branch Seal
Signature Number 
Date:
Additional information, if any: