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Get India Karur Vysya Bank ATM Claims Chargeback Form

ATM CLAIMS - CHARGEBACK FORM To The Manager Karur Vysya Bank Branch. Date Dear Sir REG CHARGE BACK FOR ATM/POS TRANSACTION SL PARTICULARS Account Holder Name Account Number ATM Card Number ATM Owner Bank Location / Merchant Details Address Date of Transaction Transaction No Claim Amount DETAILS Proof of Evidence Given Xerox copy of ATM /Pos Slip A cash withdrawal / purchase transaction effected by me at the address mentioned in 4 above was not completed but my account was debited for the amount. I request you to credit the above claim amount to my account. I also learnt that the above amount can be claimed back by the acquiring bank within the stipulated period from the date of settlement. In such case I authorize Karur Vysya Bank to debit my above-mentioned account for the amount without any reference to me. I also undertake to bring the account into credit in case my account is overdrawn because of the above debit. Cardholder s Signature Mobile / Phone No For Office / Branch Use only We have verified the above particulars in the system* The transaction nature is identified and found suspicious. We have also explained the settlement process to the customer and he agreed the same. Hence we made a Data Entry in the System* Claim Entered on Claim Reference No* CRN Name of Authorized Signatory Employee Code Designation Staff Signature After entering the details keep this form safe in branch file ATMCLAIMS in CRN order. -------------------- We hereby acknowledge the receipt of your claim on date for the A/c no. Amount INR and transaction date Claims received after 2 PM will be processed on the next working day Authorized Signatory Page 1 of 1. I request you to credit the above claim amount to my account. I also learnt that the above amount can be claimed back by the acquiring bank within the stipulated period from the date of settlement. In such case I authorize Karur Vysya Bank to debit my above-mentioned account for the amount without any reference to me. In such case I authorize Karur Vysya Bank to debit my above-mentioned account for the amount without any reference to me. I also undertake to bring the account into credit in case my account is overdrawn because of the above debit. I also undertake to bring the account into credit in case my account is overdrawn because of the above debit. Cardholder s Signature Mobile / Phone No For Office / Branch Use only We have verified the above particulars in the system* The transaction nature is identified and found suspicious. Cardholder s Signature Mobile / Phone No For Office / Branch Use only We have verified the above particulars in the system* The transaction nature is identified and found suspicious. We have also explained the settlement process to the customer and he agreed the same. Hence we made a Data Entry in the System* Claim Entered on Claim Reference No* CRN Name of Authorized Signatory Employee Code Designation Staff Signature After entering the details keep this form safe in branch file ATMCLAIMS in CRN order. .

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