Complaint Form
Annexure ‘A’
FORM OF COMPLAINT (TO BE LODGED)
WITH THE BANKING OMBUDSMAN
(FOR OFFICE USE ONLY)

Complaint No. ___________________ of year _________________

Date ____________________

(TO BE FILLED UP BY THE COMPLAINANT)

To
The Banking Ombudsman
(*Territorial jurisdiction, Place of BO’s office)

Dear Sir,

Sub: Complaint against …………………….(Name of the bank’s branch) of…………………………………………………………………………………(Name of
the Bank)

Being aggrieved the complainant named herein has submitted a complaint with
the above referred bank. Details of the complaint are as under:

1. NAME OF THE COMPLAINANT ………………

2. FULL ADDRESS OF THE COMPLAINANT ……………………..................................................................

   PIN CODE......................................

   PHONE NO/ FAX NO.....................................

3. COMPLAINT AGAINST (NAME AND FULL ADDRESS OF THE BRANCH/ BANK )

   PIN CODE......................................

   PHONE NO/ FAX NO.....................................

4. PARTICULARS OF BANK ACCOUNT
   (Please state nature of account viz. Savings bank/current/cash credit/term
   deposit/loan account etc. related to the subject matter of the complaint being made)

   ..................................................................................................................

5. (a) DATE OF REPRESENTATION BY THE COMPLAINANT TO THE BANK

    ............................................................................................

            (Please enclose three copies of the representation)

    (b) Whether any reminder was sent by the complainant? YES /NO

           (If yes, please enclose three copies of the reminder)

6. SUBJECT MATTER OF THE COMPLAINT (Please refer to Clause 8 of the Scheme)

    ..............................................................................................

7. DETAILS OF THE COMPLAINT (If space is not sufficient Please enclose separate sheet)

    ............................................................................................................................................

    ............................................................................................................................................

    ............................................................................................................................................

    ............................................................................................................................................

8. (a) Whether any reply (Within a period of one month after the bank concerned
         received the representation) has been received? YES / NO
        (If yes, please enclose 'three copies' of the bank's reply)

   (b) Whether the representation has been rejected ? YES/ NO
        (If yes, please enclose 'three copies' of the bank's letter)

   (c) Whether the complainant has received any other final decision of the bank?YES/ NO
        (If yes, please enclose 'three copies' of the bank's letter conveying its final decision)
        

9 NATURE OF RELIEF SOUGHT FROM THE BANKING OMBUDSMAN

    ..................................................................................................................................

           ( Please enclose ‘three copies’ of documentary proof, if any, in support of your claim)

10. NATURE AND EXTENT OF MONETARY LOSS, IF ANY, CLAIMED BY THE COMPLAINANT BY WAY OF COMPENSATION

    Rs.....................................

    (Please enclose documentary proof, if any, to show that such loss is actual loss
     caused as a direct consequence of alleged omission or commission of the bank)

11. LIST OF DOCUMENTS ENCLOSED

    (Please enclose ‘three copies’ of all the documents)

DECLARATION

1. I/ We , the complainant/s herein declare that:

1. the information furnished herein above is true and correct; and
2. I/ We have not concealed or misrepresented any fact stated in aforesaid columns and the documents submitted herewith.

2. The complaint is filed before expiry of period of one year reckoned in accordance with the provisions of Clause 9 (a) and (b) of the Scheme.
3.  

1. The subject matter of the present complaint has never been brought before the Office of the Banking Ombudsman by me/ or by any one of us or by any of the parties concerned with the subject matter to the best of my/ our knowledge.
2. The subject matter of the present complaint is not in respect of the same which was settled through the Office of the Banking Ombudsman in any previous proceedings.
3. The subject matter of the present complaint has not been decided by any forum/court/arbitrator.

4. I/We authorise the bank to disclose any such information/ documents furnished by us to the Banking Ombudsman and disclosure whereof in the opinion of the Banking Ombudsman is necessary and is required for redressal of any other complaint or our complaint.
5. I/We have noted the contents of the Banking Ombudsman Scheme, 2006.

Yours faithfully,
(Signature of Complainant)

NOMINATION

(If the complainant wants to nominate his representative to appear and make submissions on his behalf before the Banking Ombudsman or to the Office of the Banking Ombudsman, the following declaration should be submitted.)

I/We the above named complainant/s hereby nominate

Shri/Smt………………………………………….. who is not an Advocate and whose
address is ………………………………………………………………………………………………………………………………
as my/our REPRESENTATIVE in all proceedings of this complaint and confirm that any statement,
acceptance or rejection made by him/her shall be binding on me/us. He/She has signed below in my presence.

ACCEPTED

(Signature of Representative)

(Signature of Complainant)