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(Please Strike the form. if not applicable)

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No,,
:1,,.

1 When did vou come to know of the incidentl disputed transacticn?

1.1 lmmediately afterthe transaction happened through SMS on my mobile on

1.2 On updating the passbook/ statement on .16..tcux/.4023

1.3 When I attempted the next transaction at ATM on

2.
When have vou reported these unauthorized / fraudulent transactions to Bank.? r.lrr lrn ,
2.1
lmmediately after qetting SMSlnotification on my mobile on date (DD/MMffYYY)
tg.NoVf,3 to te IDa,q.lZq23 mobite number by sMS on date (ooruruxvw)
..1/i,..-*'r^.,-*L^- Sfi 1\
2.2 lmmediately after getting SMS/ notificationl email on my mobile/ mail on date
(DDIMM^/YYY) .. ..... To email id on date (DD/MM/YYYY)
2.3 lmmediately after getting SMS/notification on my mobile on date (DD/MM^/YYY)
to ........". Toll-free number on date (DDIMMffYYY) ....
3.
What was Vour qeoqraphical location on the date of the disputed transaction?
3.1 ln lndia, please specifu city
Ce*$&t!lrr
3.1 Abroad. please specifv countrv and citv
4. Yes No
Was the Mobile in your possession on the date of disputed transaction?

4.1 lf No, then

4.2 The Mobile was lost on date (DD/MMIYYYY).

4.3 I have oiven it to a relative

4.4 lf Mobile was lost, then
5. I gotthe accaunt blocked on date (DD/MMffYYY) ....15..t)*-..,..hf\$.i\
5.1 I have not qot it blocked vet
5.2 Please answer in Yesl No Yes No
10
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sl Statements (Please fill the blanks wherever applibable) 7 Please Tick

No. {!)
Wherever
applicable
6. Has any similar incident has happened to you earlier also?
Ye;
7. ln case, Bank has to take legal recourse to recover this amount from the
miscreants/ fraudsters I would cooperate with the Bank and legal
authorities?
Y"r
8. I have changed my PIN after the incident.
t\iO
o UPI App/Apps is already being used by me
Yet
10. Any new registration happened during the period of unauthorized I
fraud ulent transactions NCI

11 Any non-UPl Remote Screening App downloaded during the period

Ntc
12. Did you receive any call from anyone during before/duringlafter this/these
transactionls? \\o
13. Did you share your ATM Card No, UPI PIN or any other information like
PAN card/Aadhar Card etc., with anyone before and after the incident? No
14. Did you try to sell or purchase some item through selling
aoplicationslsites Iike OLX N\O
15 Did you search for any customer care/ contact center for any product or
services ? *. .Uc
16 Did you try to invest in any online game
\,1c
Any other information details on the above points which you feel may be useful to the Bank
in investigation. tt l;til&.$. ':rr-,rrkr c.n cl\yt^ p Ttolr- R<-\,qu*.*) , t t b* ..
",
Gn,.,-,.,.i.r.,,* . .'u.sts,l,u. . .Er. . [p.o. ... ik-r. . -cot. .{n .1.(..a*. nt.J *t* /**&"i*1. . o,Xui/r. ,:f4'
(\y...R.8=. ."1"*t .-[.:*
"n,*^'p"!il'*1n.....q.n..l"...?l.le51..X" 'stqF,rx --,r",'',lstL(
DECLARATION: I hereby affirm that the information furnished above is true to the best of
my knowledge and in case of the complaint is found to be false, I am liable for criminal
prosecution, and I indemnify the Bank the total compensation paid with interesUpenalty as
decided bv the Bank.
.l '.\/ {\/,
i\ ' :a-- ::e*-'
(Signature of the applicant)
Contact Number.... ..f.+*ft$.{t..S:i :
Address
Virtual Payment Address (VPA) of user Date: ......C.R.. rr.',okJ"...
"?C.
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11