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Cardholder Dispute Form

    Sr. No. Transaction Date as in statement Merchant Name
    (as it appears in the Bank statement/Passbook)
    Bill Amount Reference Number(RRN)
    (as appearing in Bank statement/Passbook).

    (Allowed pdf,txt files only)

    I was charged more than once for a single authorized transaction (transaction date & Amount should be same). I have done the transaction only time(s) but I have been billed time(s)

    I have erroneously transferred funds to an unintended beneficiary through

    (Please enclose a written application form and any available proof of transaction)

    I paid for this transaction by other means
    Please enclose proof of payment by other means (i.e. cash, receipt, other credit card transaction receipt etc.)

    The amount billed to my a/c is different from the amount that I had authorized. Transaction amount was but I was billed for
    (Please enclose copy of transaction receipt /charge slip which you authorized).

    I have not authorized the above transaction(s). The card is blocked/ not blocked and is in my possession/ lost/stolen. I will lodge an FIR with police for the same and submit to Branch by

    I came to know about the unauthorized transactions by (details how the fraud was known)

    (Please enclose copy of transaction receipt /charge slip which you authorized).

    I have received SMS for the transactions –

    I have shared CVV / Card No. / Card expiry date / OTP etc –

    I have cancelled the transaction but credit / refund not processed / posted to my account
    Please find enclosed credit transaction receipt / void slip / merchant's letter etc as proof.

    I have tried to withdraw cash from Bank ATM but cash not dispensed (ATM slip copy enclosed)

    I received only (amount) for ATM withdrawal but my account debited for

    (Please enclose necessary documents to support the dispute & brief about the same)

    I hereby declare that

    • All information provided above is true and to the best of my knowledge
    • I hereby authorize Kalupur Bank to investigate / correct the transaction(s) in dispute
    • Should the dispute be found invalid, I agree that, I may be liable for any processing charges incurred by the Bank in the course of the investigation

    Branch Official Name Accepting the Dispute Form: