ANNEXURE A

Common Customer Declaration cum Complaint Form

(To be obtained in case of Digital/ATM transactions Complaints)

Name____________________ Amount _________________________

Card Number________________ Date of transaction__________________
Account Number ______________ Location of ATM /Merchant (if applicable)……..
_______________
CIF Number _________________ Mobile Number_______________________

2. I had lodged my complaint on …………….... vide ticket number .................. I request that
the amount involved may be restored to my account with value date.

3. Please use the Forms for different type of complaints as under:-

1. ATM : Part 1
2. POS / e-com transactions : Part 2
3. YONO /YONO Lite/INB : Part 3
4. UPI / BHIM SBI Pay : Part 4
5. Domestic Merchant’s sites / : Part 5
/e-Commerce transactions in
UPI/BHIM SBI Pay

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 Part 1
(Please Strike the form, if not applicable)

ATM:-

A sum of ............. has been debited to my above account on ....................

1. Please tick the boxes, wherever applicable

Sl Statements Tick whichever
No. is/ are
applicable
i. I visited the ATM and did the transaction myself, but I did not receive
the money.
ii. I visited the ATM, but this transaction was not done by me.
iii. I never visited the above ATM for this transaction.
iv I confirm that my ATM card has continuously been in my
possession, I have not shared my PIN with anyone
v I confirm that my ATM card has continuously been in possession.
However, I have shared my PIN with someone

2. I hereby declare that the above statements are true and authorize the Bank to recover
any amount credited to the above account against the above-mentioned claim, if found
untrue/incorrect.

Additional details to be obtained in case of ATM transactions

Sl Statements (Please fill the blanks wherever applicable) Please

No. Tick ( √ )
Wherever
applicable
1. When did you come to know of the incident/ disputed transaction?
1.1 Immediately after the transaction happened through SMS on my
mobile on …………….
1.2 On updating the passbook/ statement on ………………
1.3 When I attempted the next transaction at ATM on
…………………………….
2. Did you visit the ATM on that day? Yes No

3. If answer to question no. 2 is yes, please select from the options given below.
3.1 Could not complete the transaction and left.

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 3.2 Could not complete the transaction at this ATM but completed the
transaction on my own at another ATM kept inside the same room.
3.3 Could not complete the transaction at this ATM but completed the
transaction with the help of someone present at another ATM kept
inside the same room.
3.4 ATM did not dispense the cash till the time I was present at ATM.
3.5 ATM screen displayed message as _____________________________
4. Please confirm as under:-
4.1 I am sure, that the ATM card was in my possession during that day
4.2 Came to know that my card was not in my possession on ………………
and got it blocked on ……………….
4.3 I had sent Mr./Ms. __________________, my ___________________
(state the relationship) to withdraw cash from ATM.
5. Please answer in Yes/ No Yes No
5.1 Has any similar incident happened to you earlier also?
5.2 Have you ever used your card on P.O.S. (card swiping machine) at
merchant outlets?
5.3 In case, Bank has to take legal recourse to recover this amount from
the miscreants/ fraudsters I would cooperate with the Bank and legal
authorities?
5.4 I have changed my PIN after the incident
6 I have registered my Mobile No. ______________ with the Bank
or
I have changed my old mobile number to new mobile number
_______________ on ___________(date) as per my request letter. (strike off
whichever is not applicable)

Any other information which you feel may be useful to the Bank in investigation.
…………………………………………………………………………………………………………
DECLARATION: I hereby affirm that the information furnished above is true to the best of
my knowledge and in case of the complaint is found to be false, I am liable for criminal
prosecution, and I indemnify the Bank the total compensation paid with interest/penalty as
decided by the Bank.

(Signature of the applicant)

Contact Number.......................................
Address ...................................................

Date: .....................................................

FOR OFFICE USE ONLY □ Verified that the ATM card is still in possession of the account
holder.
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 Part 2
(Please Strike the Form, if not applicable)

POS / e-com transactions

A sum of Rs. ____________ has been debited to my above account on date (DD/MM/YYYY)
______________. The details are provided below:

Sale Date / Reference No. Amount Merchant Name / ATM Location

Transaction Date Bank Name/ POS Txn

Please tick the relevant point:

Sl Statements (Please fill the blanks wherever applicable) Please
No. Tick ( √ )
Wherever
applicable
1. The amount of transaction is incorrect. I was charged Rs.
_________. I should have been charged Rs. _________ (charge
slip copy enclosed).
2. I have not incurred the above charge(s) but I did engage in a
transaction of Rs. on date (DD/MM/YYYY) ________ at the same
merchant outlet (charge slip copy enclosed). I have been billed more
than once for the charge. I have authorized only one of these charges.
3. I have settled the charge directly with the Merchant Establishment
through Cash/Cheque/Other _______________________ (Circle one
and specify). (Enclosed is the copy of the RECEIPT issued by the
Merchant Establishment evidencing direct settlement).
4. Expected to receive goods/services by date (DD/MM/YYYY)
_______________ against the above charge(s) from the Merchant
Establishment. The goods / services have never been received.
(Enclosed is a copy of my correspondence with the Merchant
Establishment).
5. I returned the merchandise against the above charge (Enclosed is a
copy of the postal / courier receipt evidencing return of merchandise
and my correspondence with the Merchant Establishment).
6. I cancelled the subscription / membership / policy (circle one) against
the above charge(s) on date (DD/MM/YYYY) _______________.
(Enclosed is a copy of my letter / email to the Merchant Establishment
& Cancellation confirmation from the Merchant Establishment).

4
Sl Statements (Please fill the blanks wherever applicable) Please
No. Tick ( √ )
Wherever
applicable
7. The merchant did not process Credit / Refund as agreed (Enclosed is
copy of Credit Slip / Refund document)
8. In case of POS/ATM transactions: I declare that I am in possession of
the card at the time of the incident.
9. Number of Debit Cards in Account— / Prepaid card
10. HOTEL RESERVATION
10.1 I have cancelled the reservation on date (DD/MM/YYYY)
____________under the cancellation code
10.2 I have not made any reservation.
11. ATM DISPUTE (International Transactions)

11.1 I tried to withdraw cash from ATM, but no cash was dispensed.
11.2 I tried to withdraw

Additional information:

Sl Statements (Please fill the blanks wherever applicable) Please Tick

No. (√)
Wherever
applicable
1. When did you come to know of the incident/ disputed transaction?
1.1 Immediately after the transaction happened through SMS on my mobile
on …………….
1.2 On updating the passbook/ statement on ………………

1.3 When I attempted the next transaction at ATM on

…………………………….
2. What was your geographical location on the date of the disputed transaction?
2.1 In India, please specify city
2.2 Abroad, please specify country and city
2.3 Was the Debit Card Prepaid card in your possession on the date of Yes No
disputed transaction?
3. If No, then
3.1 The card was lost on date (DD/MM/YYYY) …………………………….
3.2 I have given it to a relative

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 Sl Statements (Please fill the blanks wherever applicable) Please Tick
No. (√)
Wherever
applicable
3.3 If the card was lost, then
4 I got it blocked on date (DD/MM/YYYY) …………………………….
5 I have not got it blocked yet
6 Please answer in Yes/ No Yes No
6.1 Has any similar incident has happened to you earlier also?
6.2 In case, Bank has to take legal recourse to recover this amount from
the miscreants/ fraudsters I would cooperate with the Bank and legal
authorities?
6.3 I have changed my PIN after the incident.

Any other information which you feel may be useful to the Bank in investigation.
…………………………………………………………………………………………………………
………………………………………………….………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………

DECLARATION: I hereby affirm that the information furnished above is true to the best of
my knowledge and in case of the complaint is found to be false, I am liable for criminal
prosecution, and I indemnify the Bank the total compensation paid with interest/penalty as
decided by the Bank.

(Signature of the applicant)

Contact Number.......................................
Address ...................................................

Date: .....................................................

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 Part 3
(Please Strike the form, if not applicable)

YONO/ YONO Lite/ INB transactions

A sum of Rs…………………….. has been debited to my above account on date ………….

(DD/ MM/ YYYY). The details are provided below:

Transaction Date Transaction reference number Amount Registered Mobile number

Please tick the relevant point:

Sl Statements (Please fill the blanks wherever applicable) Please
No. Tick ( √ )
Wherever
applicable
1. o I certify that the transactions/charge(s) listed above have been
done/incurred by me and I have reported these to Bank on
....................(date) through SMS/ email/ Toll-free number ………….
2. o I certify that the transactions listed above have NOT been done by
me. The Mobile with YONO App is in my absolute possession.
3. o I certify that the transactions listed above have NOT been done by
me. The Mobile with YONO App is NOT in my possession. The
Mobile was:-
3.1 Lost
3.2 Stolen
3.3 Never Installed the App
Any other information which you feel may be useful to the Bank in investigation.
………………………………………………………………………………………………………
DECLARATION: I hereby affirm that the information furnished above is true to the best of
my knowledge and in case of the complaint is found to be false, I am liable for criminal
prosecution, and I indemnify the Bank the total compensation paid with interest/penalty as
decided by the Bank.

(Signature of the applicant)

Contact Number.......................................
Address ...................................................
Date: .....................................................

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 Part 4
(Please Strike the form, if not applicable)

UPI/BHIM SBI Pay

A sum of Rs. has been debited to my above account on date

(DD/MM/YYYY) . The details are provided below:

Transaction Remitter VPA Amount Beneficiary VPA

/ Sale Date and reference & Bank Name /
number Merchant name

Please tick the relevant point:

Sl Statements (Please fill the blanks wherever applicable) Please
No. Tick ( √ )
Wherever
applicable
1. I certify that the transactions/charge(s) listed above have been done/
incurred by me and I have reported these to Bank on through SMS/
email/Toll-free number ……………………….

2. I certify that the transactions/charge(s) listed above have NOT been done
/ incurred by me nor have I received any goods / services. The Mobile
with BHIM SBI Pay/UPI App is in my absolute possession.

3. I certify that the transactions/charge(s) listed above have NOT been done
/ incurred by me nor have I received any goods / services. The Mobile
with BHIM SBI Pay/UPI App IS NOT in my possession. The Mobile was.
3.1 Lost
3.2 Stolen
3.3 Never Installed the App
4. The amount of transaction is incorrect. I was charged
Rs……….., I should have been charged Rs.
(Transaction message/charge slip copy enclosed).
5. I have not done/incurred the above transaction/charge(s) but I did engage
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 Sl Statements (Please fill the blanks wherever applicable) Please
No. Tick ( √ )
Wherever
applicable
in a transaction of Rs.______on date (DD/MM/YYYY) _____at the same
beneficiary/merchant outlet (charge slip copy enclosed). I have been billed
more than once for the charge. I have authorized only one of these
charges.
6. I have settled the charge directly with the Merchant Establishment through
Cash/Cheque/Other
7. I have settled the charge directly with the Merchant Establishment through
Cash / Cheque / Other (Circle One & Specify). I expected to receive
goods/services by date ……….DD/MM/YYYY)
8. The goods / services have never been received. (Enclosed is a copy of my
correspondence with the Merchant Establishment).
9. I returned the merchandise against the above charge (Enclosed is a copy
of the postal / courier receipt evidencing return of merchandise and my
correspondence with the Merchant Establishment).
10. I cancelled the subscription / membership / policy against the above
charge(s) on date (DD/MM/YYYY)
11. The merchant did not process Credit / Refund as agreed (Enclosed is copy
of Credit Slip / Refund document)
12. HOTEL RESERVATION: I have cancelled the reservation on date
(DD/MM/YYYY) ________________________under the cancellation
code . I have not made any reservation.

Any other information which you feel may be useful to the Bank in investigation.
……………………………………………………………………………………………………………
……………………………………………….……………………………………………………………
……………………………………………………………………………………………………………
DECLARATION: I hereby affirm that the information furnished above is true to the best of my
knowledge and in case of the complaint is found to be false, I am liable for criminal prosecution,
and I indemnify the Bank the total compensation paid with interest/penalty as decided by the
Bank.

(Signature of the applicant)

Contact Number.......................................
Address ...................................................

Date: .....................................................
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 Part 5
(Please Strike the form, if not applicable)

P2P Transactions & Domestic Merchant’s sites/e-Commerce transactions in UPI/BHIM

SBI Pay

Sl Statements (Please fill the blanks wherever applicable) Please Tick

No. (√)
Wherever
applicable
1. When did you come to know of the incident/ disputed transaction?
1.1 Immediately after the transaction happened through SMS on my mobile on
…………….
1.2 On updating the passbook/ statement on ………………

1.3 When I attempted the next transaction at ATM on

…………………………….
2.
When have you reported these unauthorized / fraudulent transactions to Bank.?
2.1
Immediately after getting SMS/notification on my mobile on date (DD/MM/YYYY)
……………. to ………………. mobile number by SMS on date (DD/MM/YYYY)
…………….
2.2 Immediately after getting SMS/ notification/ email on my mobile/ mail on date
(DD/MM/YYYY) ……………. To email id on date (DD/MM/YYYY)
2.3 Immediately after getting SMS/notification on my mobile on date (DD/MM/YYYY)
…………….. to ………. Toll-free number on date (DD/MM/YYYY) …………..
3.
What was your geographical location on the date of the disputed transaction?
3.1 In India, please specify city

3.1 Abroad, please specify country and city

4. Yes No
Was the Mobile in your possession on the date of disputed transaction?

4.1 If No, then

4.2 The Mobile was lost on date (DD/MM/YYYY)… ……….

4.3 I have given it to a relative

4.4 If Mobile was lost, then
5. I got the account blocked on date (DD/MM/YYYY) …………………………….
5.1 I have not got it blocked yet
5.2 Please answer in Yes/ No Yes No
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Sl Statements (Please fill the blanks wherever applicable) Please Tick
No. (√)
Wherever
applicable
6. Has any similar incident has happened to you earlier also?
7. In case, Bank has to take legal recourse to recover this amount from the
miscreants/ fraudsters I would cooperate with the Bank and legal
authorities?
8. I have changed my PIN after the incident.
9. UPI App/Apps is already being used by me
10. Any new registration happened during the period of unauthorized /
fraudulent transactions
11. Any non-UPI Remote Screening App downloaded during the period
12. Did you receive any call from anyone during before/during/after this/these
transaction/s?
13. Did you share your ATM Card No, UPI PIN or any other information like
PAN card/Aadhar Card etc., with anyone before and after the incident?
14. Did you try to sell or purchase some item through selling
applications/sites like OLX
15 Did you search for any customer care/ contact center for any product or
services ?
16 Did you try to invest in any online game
Any other information details on the above points which you feel may be useful to the Bank
in investigation.
…………………………………………………….……………………………………………….…
……………………………………………………………………………………………………
DECLARATION: I hereby affirm that the information furnished above is true to the best of
my knowledge and in case of the complaint is found to be false, I am liable for criminal
prosecution, and I indemnify the Bank the total compensation paid with interest/penalty as
decided by the Bank.

(Signature of the applicant)

Contact Number.......................................
Address ...................................................
Virtual Payment Address (VPA) of user Date: ................................................

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