The Kalupur commercial co-op bank Ltd. » 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).

Attach annexure if there are more than two transactions.
(Allowed pdf,txt files only)

I dispute the above mentioned transaction(s) for the following reason (please tick one box only)

Duplicate Billing

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)

Transferred to Wrong Account

I have erroneously transferred funds to an unintended beneficiary through IMPSUPI

Reference No

Amount

Date of Transaction

Remitter Customer A/c No

Wrong Beneficiary Account No

Correct Beneficiary A/c No

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

Paid by other means

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

Incorrect Amount

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).

Fraud

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 – YesNo

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

Refund / Credit not processed
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.

ATM withdrawal

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

Partial Cash received

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

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

Cardholder Declaration: 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

Customer Signature (stamp & sign, if any)

Date

For official use:
Branch Official Name Accepting the Dispute Form:

Date & Time

Sign/Stamp of Branch official

Branch Stamp

Card block date

Physical verification of the card done – YesNo