Unauthorized Electronic Transaction: Complaint Registration

Enter exact amount upto two decimals.

Enter details of one unauthorized transaction (Mandatory*).

Enter details of other unauthorized transactions (If any).

I hereby declare that neither me nor my family member / representative performed / authorized the above transaction(s).
Further I hereby declare that I have not shared my login credentials / PIN / password with any other person.
I declare that above given information is true and correct to the best of my knowledge.
I understand that I can be held liable for all charges incurred if dispute raised by me is found invalid.
I agree to pay the charges levied by the bank for the same including the cost incurred for investigation of my claim.
I hereby authorize the Bank to deactivate the card on which the unauthorized transaction took place.
   *I acknowledge the above terms and conditions.

Fields with * mark are mandatory.