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STATE BANK OF INDIA

APPLICATION FORM
ATM TRANSACTION DISPUTE
(Please submit in duplicate and obtain an acknowledged copy with date)

Name_____________________________
Amount `_________________________
Card Number_______________________
Date of transaction__________________
Account Number ____________________
Location of the ATM _______________

A sum of `............. has been debited to my above account on ....................,

(i) I visited the ATM and did the transaction myself, but I did not receive the money.
(ii) I visited the ATM but this transaction was not done by me.
(iii) I never visited the above ATM.
(Tick whichever is/ are applicable)

2. I had lodged my complaint on …………….... vide ticket number .................. which has been
closed by the Bank on ………………… stating that the transaction was successful as per
transaction slip/ eJ. I have been advised by the Bank that this complaint has been closed.
I am not satisfied with the decision of the Bank and would request you to re-investigate
the matter.

3. I confirm that my ATM card has continuously been in my possession and I have not
shared my PIN with anyone.

(Signature of the applicant) Contact Number.......................................

Address ...................................................
.....................................................

FOR OFFICE USE ONLY

□ Verified that the ATM card is still in possession of the account holder.

Date: Authorised Signatory

Enclosure-SOP_fraudulent transactions
 प्रारूऩ अ

बायतीम स्टे ट फैंक

आवेदन ऩत्र
ए टी एभ रेन दे न वववाद
(कृऩमा दो प्रततमों भें जभा कयें एवॊ एक प्रतत ददनाॊक सदित अभबस्वीकृत कया रें )

नाभ ......................................................... याभि ( `) ..................................................

कार्ड क्रभाॊक ............................................... रेन दे न की ततथि ...................................
खाता क्रभाॊक ............................................. ए टी एभ की स्स्ितत ...............................

भेये उऩयोक्त खाता क्रभाॊक से ददनाॊक ....................... को ` ...................... नाभे िुए,

(क) भैं ए टी एभ ऩय गमा एवॊ स्वमॊ रेन दे न ककमा ऩयॊ तु याभि प्राप्त निीॊ िुई।
(ख) भैं ए टी एभ ऩय गमा ऩयॊ तु रेन दे न भैंने निीॊ ककमा।
(ग) भैं ए टी एभ ऩय कबी निीॊ गमा।
(जो रागू िो , उसे दटक कयें )

2. भैंने ददनाॊक ............... को ...................... दटकट सॊख्मा ........................... के अॊतगडत भेयी

भिकामत दर्ड कयी स्जसे फैंक ने ददनाॊक ........................ को मि किते िुए कक रेन दे न ऩर्ची / eJ के आधाय
ऩय रेन दे न सपर ऩामा गमा , फॊद कय ददमा। भैं फैंक के तनर्डम से सन्तष्ट ु निीॊ िूॉ एवॊ आऩसे भाभरे की ऩनु ः
जाॉर्च का अनुयोध कयता/ कयती िूॉ।

3. भैं ऩुवष्ट कयता/ कयती िूॉ कक भेया ए टी एभ कार्ड रगाताय भेये कब्जे भें यिा िै औय भैंने अऩना PIN
ककसी को निीॊ फतामा िै ।

(आवेदनकताड के िस्ताक्षय) सॊऩकड सॊ ..................................................

ऩता ....................................................
...................................................

केवर कामाडरम प्रमोग िे तु

□ तनस्ित ककमा कक ए टी एभ कार्ड अबी बी खाता धायक के कब्जे भें िै ।

ददनाॊक: अथधकृत िस्ताक्षयकताड

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 Format-B/ प्रारूऩ फ
Other Important Information
अन्म आवश्मक सर्च
ू ना

1. When did you come to know of the incident/ disputed transaction?

1. इस घटना/ प्रवववष्ट के फाये भे आऩको कफ ऩता र्चरा?

 Immediately after the transaction happened through SMS on my mobile on ……………..

 On updating the pass book/ statement on ………………
 When I attempted the next transaction at ATM on …………………………….

 प्रवववष्ट के तुयॊत ऩिात भेये भोफाइर ऩय ददनाॊक …………….. को SMS द्वाया।

 ददनाॊक ................... को ऩासफुक अद्यतन / वववयर्ी प्राप्त कयने ऩय।
 ददनाॊक ................... को ऩुनः प्रवववष्ट कयने ऩय।

2. Did you visit the ATM on that day?

2. क्मा आऩ उस ददन ए टी एभ ऩय गए िे?

 Yes  िाॉ
 No  निीॊ

3. If answer to question no. 2 is yes, please select from the options given below.
3. मदद प्रश्न सॊ 2 का उत्तय िाॉ िै , तो कृऩमा नीर्चे ददमे गए ववकल्ऩों भें से र्चन
ु ें।

 Could not complete the transaction and left

 Could not complete the transaction at this ATM but completed the transaction on my own
at another ATM kept inside the same room.
 Could not complete the transaction at this ATM but completed the transaction with the help
of someone present at another ATM kept inside the same room.

 प्रवववष्ट ऩूर्ड निीॊ िोने ऩय र्चरे गए।

 इस ATM ऩय प्रवववष्ट ऩूर्ड निीॊ कय सके ऩयॊ तु उसी कक्ष भें दस
ू ये ATM ऩय स्वमॊ प्रवववष्ट ऩूर्ड कयी।
 इस ATM ऩय प्रवववष्ट ऩर्
ू ड निीॊ कय सके ऩयॊ तु उसी कक्ष भें दस
ू ये ATM ऩय ककसी अन्म की भदद से
प्रवववष्ट ऩूर्ड कयी।

4. If the answer to question no. 2 is no,

4. मदद प्रश्न सॊ 2 का उत्तय निीॊ िै तो,

 Sure that the ATM card was in my possession during that day
 Came to know that my card was not in my possession on ……………… and got it blocked on
……………….
P. T. O. कृ. ऩ.ृ उ.

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Enclosure_SOP_fraudulent transaction
  तनस्ित िूॉ कक उस ददन कार्ड भेये कब्र्े भें िा।
 ददनाॊक .................. को ऩता र्चरा कक कार्ड भेये कब्र्े भें निीॊ िा , औय ददनाॊक ........... को इसे
ब्रॉक कयवामा।

5. Has any similar incident has happened to you earlier also?

5. क्मा ऐसी घटना आऩके साि ऩिरे बी िुई िै ?

 Yes  िाॉ
 No  निीॊ

6. Have you ever used your card on P.O.S. (card swiping machine) at merchant outlets?
6. क्मा आऩने अऩना कार्ड कबी व्माऩारयक प्रततष्ठानों ऩय P.O.S. (कार्ड स्वाइवऩॊग भिीन) ऩय प्रमोग ककमा
िै ?

 Yes  िाॉ
 No  निीॊ

7. In case, Bank has to take legal recourse to recover this amount from the miscreants/
fraudsters I would cooperate with the Bank and legal authorities?
7. मदद फैंक फदभािों/ धोखेफार्ों से वसूरी के भरए क़ानूनी प्रकक्रमा अऩनाती िै तो भैं फैंक एवॊ क़ानूनी
अथधकारयमों के साि सिमोग करूॉगा/ करूॉगी?

 Yes  िाॉ
 No  निीॊ

8. I have changed my PIN after the incident.

8. भैंने घटना के ऩिात अऩना वऩन फदर भरमा िै ।

 Yes  िाॉ
 No  निीॊ

9. Any other information which you feel may be useful to the Bank in investigation.
9. कोई अन्म सूर्चना जो आऩके अनुसाय फैंक को जाॊर्च भें उऩमोगी िो सकती िै ।

…………………………………………………………………………………………………………………………………………………………….

…………………………………………………………………………………………………………………………………………………………….

Name & Signature of account holder खाताधायक का नाभ एवॊ िस्ताक्षय

Account Number खाता सॊ
Contact Number सॊऩकड सॊ

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 Format-C

RECOMMENDATION OF THE BRANCH MANAGER

 The request of the customer appears to be genuine as per our investigation of
the transaction and is eligible under SOP.

 The conduct of the account has been

Satisfactory Not Satisfactory

 There have been/ not been any such claims previously in the account.

 The complaint was lodged in the CMS on ……………….with ticket no.

............... and closed on ………………………... with following remarks:

 Remarks, if any.
............................................................................................................................
............................................................................................................................
The complaint is forwarded with all relevant papers/ details as under for
consideration under the SOP.

Branch Manager/ Chief Manager/ Assistant General Manager

Mobile number....................... e-mail ID....................................
________________________________________________________________________________
CHECKLIST
__________________________________________________________________________________
DOCUMENTS TO BE SUBMITTED ALONG WITH APPLICATION OF THE CUSTOMER

□ APPLICATION FROM THE CUSTOMER

□ FORM CONTAINING ‘OTHER IMPORTANT INFORMATION’

□ PRINT OUT OF THE CLOSED CMS COMPLAINT (SCREEN SHOT)

□ COPY OF EJ / JP LOG

□ IN CASE THE TRANSACTION HAS HAPPENED AT THE BRANCH ATM,

 DVSS RECORDING OF THE TRANSACTION ALONG WITH 3 PRECEDING AND 3

SUCCEEDING TRANSACTIONS OF THE DISPUTED TRANSACTION

 CERTIFICATE REGARDING NO EXCESS CASH FOUND AGAINST THE DISPUTED

TRANSACTION IN THE ATM.

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 Format-D

GENERAL MANAGER
Network- I/II/III/IV

ATM DISPUTE: FRAUDULENT TRANSACTION FOR `………….

BRANCH: ________________REGION: ________________A.O. ______________
Shri/ Smt./Ms
Recommendation for restoration / rejection of disputed amount to customer’s account
By debit to Recalled Assets account at the Branch

Name of the customer :

Account number :
Date of transaction :
Disputed amount :
Nature of fraud : Cloning/ EPP Tampering
Staff involvement : Yes/ No

Findings of the Committee:

……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….

Our Recommendation:
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….

Asstt. General Manager Asstt. General Manager Asstt. General Manager

ATM (Operations) (Fraud Monitoring Cell) (Customer Service)

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