VIJAYA BANK
 
APPLICATION FORM for 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 addres of the complainant  
Pin Code  
Phone No. / FAX No.  
3   Complaint Against ( Name and Full Addres 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 ? (If yes, please enclose three copies of the reminder)
 
 
 Yes
 
 No
 
6. Subject Matter of the Complaint ( Please refer to Clause 12 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 ? (If yes, please enclose three copies of the bank’s reply)
 
 Yes
 
 No
 
b) Whether the representation has been rejected ?
(If yes, please enclose three copies of the bank’s letter)
 
 Yes
 
 No
c) Whether the complainant has received any other final decision of the bank ? (If yes, please enclose ‘three copies’ of the bank’s letter conveying its final decision)
 
 Yes
 
 No
9. Nature of Relief Saught 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)
12. DECLARATION
1. I/We, the complainant/s herein declare that
(a) the information furnished herein above is true and correct, and
(b) 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 13(3) (a) and (b) of the Scheme.
3.
(a) 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.
(b) 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.
(c) The subject matter of the present complaint has not been decided by any forum/court/arbitrator.
The subject matter of the present complaint is pending since (please mention the date when the matter was filed) _____________ before _____________ (Please mention the name of the forum/court/arbitrator before whom the complaint is pending) and the proceedings are likely to take longer time in its final adjudication as contemplated in Clause 13(4) (c) of the Scheme.
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, 2002.


Yours faithfully,


(Signature)
(Complainant.)

 
13. 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)