ANNEXUREA

CommonCustomerDeclarationcumComplaintForm
(TobeobtainedincaseofDigital/ATMtransactions Complaints)

Name MOHANRAJ P Amount 3750

CardNumber 5446700128874969 Dateof transaction 14/07/2025
Account Number 37020984247 LocationofATM/Merchant (ifapplicable)……..

CIF Number 89889741491 MobileNumber 9944530247

2. Ihad lodgedmycomplaint on 14/07/2025 vide 713458774 ticketnumber I

requestthat
theamountinvolvedmayberestoredtomyaccountwithvaluedate.

3. PleaseusetheFormsfordifferenttypeofcomplaintsasunder:-

1. ATM : Part 1
2. POS/e-com transactions : Part 2
3. YONO/YONOLite/INB : Part 3
4. UPI/ BHIMSBI Pay : Part 4
5. DomesticMerchant’ssites/ : Part 5
/e-Commercetransactionsin
UPI/BHIM SBI Pay

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 Part 1
(PleaseStriketheform,ifnotapplicable)

ATM:-

Asumof.............hasbeendebitedtomyaboveaccounton....................

1. Pleaseticktheboxes,wherever applicable
Sl Statements Tickwhichever
No. is/ are
applicable
i. IvisitedtheATManddidthetransactionmyself,butIdidnotreceiv
e
themoney.
ii. IvisitedtheATM,butthistransactionwasnotdoneby me.
iii. InevervisitedtheaboveATMforthistransaction.
iv IconfirmthatmyATMcardhascontinuouslybeeninmypossessi
on, I have not shared my PIN with anyone
v IconfirmthatmyATMcardhascontinuouslybeeninpossession.
However,IhavesharedmyPINwithsomeone

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.

AdditionaldetailstobeobtainedincaseofATMtransactions

Sl Statements(Pleasefilltheblankswhereverapplicable) Please
No. Tick ( √ )
Wherever
applicable
1. Whendidyoucometoknowoftheincident/disputedtransaction?
1.1 ImmediatelyafterthetransactionhappenedthroughSMSonmy
mobileon …………….
1.2 Onupdatingthepassbook/statementon ………………
1.3 When I attempted the next transaction at ATM on
…………………………….
2. DidyouvisittheATMonthatday? Yes No

3. Ifanswertoquestionno.2isyes,pleaseselectfromtheoptionsgivenbelow.
3.1 Couldnotcompletethetransactionandleft.

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 3.2 CouldnotcompletethetransactionatthisATMbutcompletedthe
transactiononmyownatanotherATMkeptinsidethesameroom.
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 ATMdidnotdispensethecashtillthetimeIwaspresentatATM.
3.5 ATMscreendisplayedmessageas
4. Pleaseconfirmasunder:-
4.1 Iamsure,thattheATMcardwasinmypossessionduringthatday
4.2 Cametoknowthatmycardwasnotinmypossessionon………………
and got it blocked on ……………….
4.3 I had sentMr./Ms. , my
(statetherelationship)towithdrawcashfromATM.
5. PleaseanswerinYes/No Yes No
5.1 Hasanysimilarincidenthappenedtoyouearlieralso?
5.2 HaveyoueverusedyourcardonP.O.S.(cardswipingmachine)at
merchantoutlets?
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 IhavechangedmyPINaftertheincident
6 I have registered myMobile No. with theBank
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)

Anyother informationwhichyoufeelmaybeusefulto theBankininvestigation.

…………………………………………………………………………………………………………
DECLARATION:I hereby affirm that the information furnished above is true to the
best of
myknowledgeandincaseofthecomplaintisfoundtobefalse,Iamliableforcriminal
prosecution, and I indemnify the Bank the total compensation paid with
interest/penalty as decided by the Bank.

(Signatureoftheapplicant)
ContactNumber.......................................
Address ...................................................

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

3
FOR OFFICE USE ONLY □ Verified that the ATM card is still in possession of the
account holder.

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 Part 2
(PleaseStrikethe Form,ifnotapplicable)

POS/e-com transactions

AsumofRs. hasbeendebitedtomyaboveaccountondate(DD/MM/YYYY)
.Thedetailsareprovidedbelow:

Sale Date / ReferenceNo. Amount MerchantName/ATMLocation

TransactionDate Bank Name/ POS Txn

Pleaseticktherelevantpoint:
Sl Statements(Pleasefilltheblankswhereverapplicable) 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) atthe
same merchant outlet (charge slip copy enclosed). I have
been billed more
thanonceforthecharge.Ihaveauthorizedonlyone ofthese
charges.
3. I have settled the charge directly with the Merchant
Establishment through Cash/Cheque/Other (Circleone
and specify). (Enclosed is the copy of the RECEIPT issued by
the Merchant Establishment evidencing direct settlement).
4. Expectedtoreceivegoods/servicesbydate(DD/MM/YYYY)
against the abovecharge(s) from the
Merchant Establishment. The goods / services have never
been received. (Enclosed is a copy of my correspondence
with the Merchant Establishment).
5. Ireturned the merchandise against the above charge
(Enclosed is a
copyofthepostal/courierreceiptevidencingreturnofmerchandise
andmycorrespondencewiththeMerchantEstablishment).
6. I cancelled the subscription / membership / policy (circle one)
against theabovecharge(s)ondate(DD/MM/YYYY)
5
 .
(Enclosedis acopyof myletter / emailto theMerchant
Establishment & Cancellation confirmation from the Merchant
Establishment).
Sl Statements(Pleasefilltheblankswhereverapplicable) Please
No. Tick ( √ )
Wherever
applicable
7. The merchant did not process Credit / Refund as agreed
(Enclosed is copy of Credit Slip / Refund document)
8. IncaseofPOS/ATMtransactions:IdeclarethatIaminpossessionof
thecardatthetimeoftheincident.
9. NumberofDebitCardsinAccount—/Prepaid card
10. HOTELRESERVATION
10.1 I have cancelled the reservation on date (DD/MM/YYYY)
underthecancellationcode
10.2 I have notmade anyreservation.
11. ATMDISPUTE(InternationalTransactions)

11.1 ItriedtowithdrawcashfromATM,butnocash was dispensed.

11.2 Itried to withdraw

Additionalinformation:

Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
Wherever
applicable
1. Whendidyoucometoknowoftheincident/disputedtransaction?
1.1 ImmediatelyafterthetransactionhappenedthroughSMSonmymo
bile on …………….
1.2 Onupdatingthepassbook/statementon ………………

1.3 When I attempted the next transaction at ATM on

…………………………….
2. Whatwasyourgeographicallocationonthedateof thedisputedtransaction?
2.1 InIndia,pleasespecifycity
2.2 Abroad,pleasespecifycountryandcity
2.3 WastheDebitCardPrepaidcardinyourpossessiononthedateof Yes No

6
 disputedtransaction?
3. IfNo,then
3.1 Thecardwaslostondate(DD/MM/YYYY) …………………………….
3.2 Ihavegivenitto a relative

Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
Wherever
applicable
3.3 Ifthecardwaslost,then
4 Igotitblockedondate(DD/MM/YYYY)…………………………….
5 Ihavenotgotitblockedyet
6 PleaseanswerinYes/No Yes No
6.1 Hasanysimilarincidenthashappenedtoyouearlieralso?
6.2 Incase,Bankhastotakelegalrecoursetorecoverthisamountfrom
the miscreants/ fraudsters I would cooperate with the Bank
and legal authorities?
6.3 IhavechangedmyPINafterthe incident.

Anyotherinformationwhichyoufeelmaybeusefulto theBankininvestigation.
…………………………………………………………………………………………………………
………………………………………………….………………………………………………………
…………………………………………………………………………………………………………
…………………………………………………………………………

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.

(Signatureoftheapplicant)
ContactNumber.......................................
Address ...................................................

Date:.....................................................
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8
 Part 3
(PleaseStriketheform,ifnotapplicable)

YONO/YONOLite/INBtransactions

A sum of Rs…3750………………….. has been debited to my above account on

date …14/07/2025…. (DD/ MM/ YYYY). The details are provided below:

TransactionDate Transactionreferencenumb Amoun RegisteredMobilenumb

er t er
14/07/2025 IGATBARDHO 3750 9944530247
Pleaseticktherelevantpoint:
Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
Wherever
applicable
1. Icertifythatthetransactions/
charge(s)listedabovehavebeendone/
incurredbymeandIhavereportedthesetoBankon
...14/07/2025.................(date)throughSMS/email/Toll- √
freenumber………….
2. IcertifythatthetransactionslistedabovehaveNOTbeendoneby
me.TheMobilewithYONOAppisinmyabsolutepossession. √
3. I certify that the transactions listed above have NOT been
done by √
me.TheMobilewithYONOAppisNOTinmypossession.The
Mobilewas:-
3.1 Lost
3.2 Stolen √
3.3 NeverInstalledtheApp
Anyotherinformationwhichyoufeelmaybeusefulto theBankininvestigation.
…I received a link and installed the YONO SBI app APK. After installation, I received an OTP message, and
subsequently, funds were withdrawn from my account.
……………………………………………………………………………………………………
DECLARATION:I hereby affirm that the information furnished above is true to the
best of
myknowledgeandincaseofthecomplaintisfoundtobefalse,Iamliableforcriminal
prosecution, and I indemnify the Bank the total compensation paid with
9
interest/penalty as decided by the Bank.

(Signatureoftheapplicant)
ContactNumber.....9944530247...........................
Address ............410 J/B SHANTHINAGAR, KOOSALIPATTI,KOVILPATTI,
628502.......................................
Date:......30/07/2025...............................................

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 Part 4
(PleaseStriketheform,ifnotapplicable)

UPI/BHIMSBIPay

A sum of Rs. hasbeendebitedtomyaboveaccountondate

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

Transaction Remitter VPA Amount BeneficiaryVPA

/SaleDate and reference &BankName/
number Merchantname

Pleaseticktherelevantpoint:
Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
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. Icertifythatthe
transactions/charge(s)listedabovehaveNOTbeendone
/ incurred by me nor have I received any goods / services. The
Mobile with BHIM SBI Pay/UPI App is in my absolute possession.
3. Icertifythatthetransactions/
charge(s)listedabovehaveNOTbeendone
/ incurred by me nor have I received any goods / services. The
Mobile
withBHIMSBIPay/UPIAppISNOTinmypossession.TheMobilewas.
3.1 Lost
3.2 Stolen
3.3 NeverInstalledtheApp
4. The amount of transaction is incorrect. I was
charged Rs……….., I should have

11
 been charged Rs.
(Transactionmessage/chargeslipcopyenclosed).
5. Ihavenotdone/incurredtheabovetransaction/
charge(s)butIdidengage
Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
Wherever
applicable
in a transaction of Rs. on date (DD/MM/YYYY)
atthesame
beneficiary/merchantoutlet(chargeslipcopyenclosed).Ihavebeen
billed
morethanonceforthecharge.Ihaveauthorizedonlyoneofthese
charges.
6. IhavesettledthechargedirectlywiththeMerchantEstablishmentthro
ugh Cash/Cheque/Other
7. IhavesettledthechargedirectlywiththeMerchantEstablishmentthr
ough Cash / Cheque / Other (Circle One & Specify). I expected
to receive goods/services by date DD/MM/YYYY)
8. Thegoods/serviceshaveneverbeenreceived.
(Enclosedisacopyofmy correspondence with the Merchant
Establishment).
9. Ireturnedthemerchandiseagainsttheabovecharge(Enclosedisaco
py of the postal / courier receipt evidencing return of
merchandise and my correspondence with the Merchant
Establishment).
10. Icancelledthesubscription/membership/policyagainsttheabove
charge(s) on date (DD/MM/YYYY)
11. ThemerchantdidnotprocessCredit/
Refundasagreed(Enclosediscopy of Credit Slip / Refund
document)
12. HOTEL RESERVATION: I have cancelled the reservation on
date (DD/MM/YYYY)
underthecancellation code . I have not made
any reservation.

Anyotherinformationwhichyoufeelmaybeusefulto theBankininvestigation.
……………………………………………………………………………………………………………
……………………………………………….……………………………………………………………
……………………………………………………………………………………………………………
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DECLARATION:Iherebyaffirmthattheinformationfurnishedaboveistruetothebestofm
y
knowledgeandincaseofthecomplaintisfoundtobefalse,Iamliableforcriminalprosecuti
on, and I indemnify the Bank the total compensation paid with interest/penalty as
decided by the Bank.

(Signatureoftheapplicant)
ContactNumber.......................................
Address ...................................................

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

13
 Part 5
(PleaseStriketheform,ifnotapplicable)

P2PTransactions&DomesticMerchant’ssites/e-CommercetransactionsinUPI/BHIMSBI
Pay

Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
Wherever
applicable
1. Whendidyoucometoknowoftheincident/disputedtransaction?
1.1 ImmediatelyafterthetransactionhappenedthroughSMSonmymobil
eon
…………….
1.2 Onupdatingthepassbook/statementon ………………

1.3 When I attempted the next transaction at ATM on

…………………………….
2.
Whenhaveyoureportedtheseunauthorized/fraudulenttransactionstoBank.?
2.1
ImmediatelyaftergettingSMS/notificationonmymobileondate(DD/MM/
YYYY)
…………….to……………….mobilenumberbySMSondate(DD/MM/YYYY)
…………….
2.2 ImmediatelyaftergettingSMS/notification/emailonmy
mobile/mailondate (DD/MM/YYYY) To email id on date
(DD/MM/YYYY)
2.3 ImmediatelyaftergettingSMS/notificationonmymobileondate(DD/MM/
YYYY)
……………..to……….Toll-freenumberondate(DD/MM/YYYY)…………..
3.
Whatwasyourgeographicallocationonthedateofthedisputedtransaction?
3.1 InIndia,pleasespecifycity

3.1 Abroad,pleasespecifycountryandcity
4. Yes No
WastheMobileinyourpossessiononthedateofdisputedtransaction?

4.1 IfNo,then
4.2 TheMobilewaslostondate(DD/MM/YYYY)… ……….

4.3 Ihavegivenitto a relative

4.4 IfMobilewaslost,then

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5. Igottheaccountblockedondate(DD/MM/YYYY)…………………………….
5.1 Ihavenotgotitblockedyet
5.2 PleaseanswerinYes/No Yes No
Sl Statements(Pleasefilltheblankswhereverapplicable) PleaseTick
No. (√)
Wherever
applicable
6. Hasanysimilarincidenthashappenedtoyouearlieralso?
7. Incase,Bankhastotakelegalrecoursetorecoverthisamountfromthe
miscreants/ fraudsters I would cooperate with the Bank and legal
authorities?
8. IhavechangedmyPINafterthe incident.
9. UPIApp/Appsisalreadybeingusedbyme
10. Anynewregistrationhappenedduringtheperiodofunauthorized/
fraudulenttransactions
11. Anynon-UPIRemoteScreeningAppdownloadedduringtheperiod
12. Did you receiveanycallfrom
anyoneduringbefore/during/afterthis/these
transaction/s?
13. DidyoushareyourATMCardNo,UPIPINoranyotherinformationlike
PANcard/AadharCardetc.,withanyonebeforeandaftertheincident?
14. Didyoutrytosellorpurchasesomeitemthrough selling
applications/sites like OLX
15 Didyousearchforanycustomercare/contactcenterforanyproductor
services ?
16 Didyoutrytoinvestinanyonlinegame
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
myknowledgeandincaseofthecomplaintisfoundtobefalse,Iamliableforcriminal
prosecution, and I indemnify the Bank the total compensation paid with
interest/penalty as decided by the Bank.

15
(Signatureoftheapplicant)
ContactNumber.......................................
Address ...................................................
VirtualPaymentAddress(VPA)ofuser Date:................................................

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