Request cum Undertaking Letter for raising Arbitration for ATM

Transaction

Date:_________
From,
_____________________________________________________,
_____________________________________________________,
_____________________________________________________,
_____________________________________________________,
_____________________________________________________,
Mobile Number:________________
To,
The Branch Manager,
Canara bank.

Sub : Consent for debiting my Account No ________________ with applicable

charges plus GST.

I request you to take up the below ATM transaction to Arbitration level and I
authorize the Bank to debit my SB/CA/OD/ODCC Account No with INR 500.00 (+
GST) towards the Arbitration Fee.

I understand that the Arbitration Fees is non-refundable, if my claim for arbitration

is not accepted.

Date of Transaction:__________________ Sequence Number:_____________

Amount of Transaction:_______________
Debit Card number:__________________

Yours Faithfully,

Signature of the Account Holder.