| Customer Type * |
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| Account Number * |
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| Name Of Complainant * |
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| Branch Code(If other than Home Branch) |
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| Mobile number * |
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| Telephone No. * |
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| E-mail * |
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| Category Of Complaints* |
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| Products & Services* |
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| Nature Of complaint* |
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| Transferee Branch* |
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| Beneficiary No/Mobile Top Up No.* |
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| Service Provider* |
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| Merchant Name* |
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| Merchant City/State* |
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| Biller Name* |
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| Beneficiary MMID* |
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| RBI Reference No.* |
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| Receiving IFSC Code* |
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Debit Card No*
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Prepaid Card No *
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Txn Amount* |
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| Beneficiary/Credit A/c* |
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Txn Id/UTR No.*
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| Transaction Date
*
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| Dispensed Amount
*
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| ATM Id/TERMINAL ID*
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| Biller Id*
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Schedule Date:
*
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| Bill Month |
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| Please Give brief details of your complaint(Max 500 Chars)
*
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*
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