Request Form for Chargeback
To,
Kotak Mahindra Bank Ltd.
Direct Banking Operations,
Kotak Infinity Tower- 21,5th Floor,
General A. K. Vaidya Marg,
Malad East, Mumbai – 400097
Fax: +91 22 66466903
Kotak Debit Card/Ecard Number:
CRN/A/c Number:__________________
Details of the disputed transaction(s) under SR # _______________:
Transaction Date Merchant Name & Location Transaction (Billed) Disputed Amount
[dd/mm/yy] Amount(INR) (INR)
Reasons for dispute (please fill as applicable):
1. I tried to withdraw Rs.___________ but ATM dispensed only Rs.__________/No Amount.
2. Duplicate/multiple billing: I have done the transaction only ______time(s) but I have been billed ____ time(s).
3. Paid by other means: Initially I had used my Kotak Debit card for payment but finally I paid by ___________ (cash
receipt/bill/etc is attached as a proof of payment).
4. The transaction Amount was Rs.__________ but I have been billed for Rs.__________ (charge slip attached as a
proof).
* Please note that if a transaction is done on a travel/hotel/movies merchant then the customer can dispute only when
the difference amount is greater than USD 25, else the customer will have to resolve the dispute with the merchant.
5. The transaction was cancelled but I have not received the credit/refund for the same (credit slip/Void
Slip/merchant’s letter is attached as a proof).* The customer must wait for 15 days from the date of cancellation before
raising the dispute.
6. I have not received the merchandise/rendered the services by expected date (dd/mm/yy) ______________.
* I contacted the merchant on date (dd/mm/yy) _________and the response was _______________________________
___________________________________________________________________________________________________
7. I have not authorized the above transaction(s).The card has been blocked and it is in my possession.
8. I do not memorize the transaction; Please retrieve the chargeslip copy for my reference.
9. I have lost my Kotak Debit Card and it has been misused, the card has been blocked as I have reported to the bank.
* Please note that the customer is liable to pay for all the transactions that have taken place on a lost card before
reporting to the bank.
10. Others (Please explain in detail. Please attach a separate letter if necessary).________________________________
____________________________________________________________________________________________________
Declaration:
I have read understood and agree to be bound by all the terms and conditions governing the Charge-back and ATMs including
as may be amended from time to time by Kotak Mahindra Bank (‘Bank’). I understand that the transaction is entirely the
responsibility of the Bank owning the Non-Kotak ATM (‘acquiring bank’) and the credit of short cash/non dispense cash into my
account shall be at the Bank’s discretion. I further understand that any such credit given by the Bank is a provisional credit to
my account and if the acquiring bank disputes any such short/non dispense cash within 45 days of the credit; the Bank shall
debit my account for the disputed amount. In case of my account not having sufficient funds for such debit by the Bank, I
undertake to deposit such shortfall amount in my account within two working days of being contacted by the Bank.
KMBL/Apr-2015/V1.0
Cardholder’s Name: Place:
Signature: Date:
Kotak Mahindra Bank Ltd. CIN: L65110MH1985PLC03813 Registered Office: 27 BKC, C 27, G Block, Bandra Kurla Complex, Bandra (E), Mumbai - 400 051. www.kotak.com
