UPI Merchant Dispute Form
A/c Nu:nber
Detotls of dispuled itens:
"tansaction Transoction 0ate Herchant Name Transaction Amt )s.uted Ant
4204sr26|69 22)2 RiAidhi.
Entorn'sta.
I am disputng the transaction(s) listed above for the below given reason a nd req uest you to
cases, (Please se.! One) sertle the
1 Duhcate-i b done only one transaction butI was billed
(TwIce/1 hrice etc
Dut I was billed for Rs.
e ànd: have not re ceived the credit/refuind for the sarme (Atta ch refund note/ mercna
'ette
a s contirmatIon that the
:
tr¡nsaction was cancelled and the credir VS due to y
4
Carcenership/Subscription/booking (**Atta ch the cancellation letter which you sen! to the merchar:
5 !oiiered uooUS/serIces and the 5ame are expe cted by Date
Con:fei ne nerchant o Date (cdd/mnm/yy)
(cll/mm/yy) But [ never received tne
and hS response
ies x detal Pleas altach a separate letter if ne Ce
ssary).
tor Internet / E-comme rce
to res olve the dispute. transactions, the customer needs to first contact the Merchant & attempt
Dertat atuon ! nereny (onfrm that the
infornaticn mentioned atbove is true and to the best of Ty
Customer Ndine knowledge
Place:
Date:
{na:
Landine / Mobile No:
6399843266
IPPB/DOP Official Detais:
Nae
EMP Sigrn and Seal:
sOL
0S34
Barab
AADHAAR
t ret 3TETR Government of India
Yy/INFORMATION
Government of lndia
Unique ldentification Authority of India
Ajc5H/ Enrolment No.: 1492/11146/04514
To
Hari Nandan
S/O: Shri Krishana.
badapura.
NANMAU.
VTC: Nanmau,
PO: Harakh,
Sub District: Nawabganj.
District: Bara Banki,
State: Uttar Pradesh,
DOB
PIN Code: 225121, Aadhaar is proof of identity, not of citizenship or date of birth (DOB).
Mobile: 9889262051 is based on information supported by proof of DOB document specified in
regulations, submitted by Aadhaar number holder.
This Aadhaar letter should be verified through either online
authentication by UIDA-appointed authentication agency or QR code
scanning using mAadhaar or Aadhaar QR Scanner app available in
app stores or using secure QR code reader app available on
www.uidai.gov.in.
Aadhaar is unigue and secure.
Documents to support identity and address should be updated in
Aadhaar after every 10 years from date of enrolment far Aadhaar.
Aadhaar helps you avail of various Govemment and Non
Government benefits/services.
3IT4hT 3TTT hHÍH / Your Aadhaar No. : Keep your mobile number and email id updated in Aadhaar.
Download mAadhaar app to avail of Aadhaar services.
2160 6855 5758 Use the feature of Lock/Unlock Aadhaaribiometrics to ensure
VID: 9114 9124 8732 6293 security when not using Aadhaar/biometrics.
Entities seeking Aadhaar are obligated to seek consent.
18/0772014 Government of India
arreT
Unique ldentification Authority of India AADHAAR
Hari Nandan
issued: fafu/DOB: 20/01/1985
RuRHN-225121
/ MALE
no. Address:
SIO: Shri Krishana, badapura, NANMAU,
Andhnar 5Nanmau, PO: Harakh, DIST: Bara Banki,
#Utar Pradesh -225121
Aadhaar is proof of identity, not of citizenship
or date of birth. It should be used with verification (online
authentication, or scanning of QR code / ofline XML).
2160 6855 5758
2160 6855 5758 VID :9114 9124 8732 6293
1947
help @uldai.gov.in | www.uldal.gov.in
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