E-SERVICE COMPLAINT FORM

Account Name

Card Number X X X X X X
Account No.
(For card related issues only)

COMPLAINT

Channel ATM POS WemaMobile Type PIN Username Password

WemaOnline USSD Banking WEB Token Airtime Recharge Cash Dispense

SMS Banking Payment/Transfer

Others Others

Description

TRANSACTION DETAILS (For failed cash dispense, funds transfer and payments only)

1.
Merchant/Bank/Location Transaction Amount Transaction Date

2.
Merchant/Bank/Location Transaction Amount Transaction Date

3.
Merchant/Bank/Location Transaction Amount Transaction Date

ADDITIONAL INFORMATION (for Visa Card only)

Complaint Merchandise not received Merchandise not rendered Date of Return

If merchandise is returned due to late delivery

Customer’s Signature

IMPORTANT NOTICE ON RESOLUTION TIMELINE

ATM ON-US ATM (REMOTE -ON-US) WEB/POS (Local) WEB/POS (Local) WEB/POS/ATM
Verve/Mastercard/VISA: Verve/Mastercard/VISA: Visa/Verve/Mastercard POS with Visa/Verve/Mastercard POS (INTERNATIONAL)
24 hours 4 Working Days documentation or receipt: without documentation or receipt: Visa/Mastercard:
7 Working Days 14 Working Days Transactions that are over 120
days have an indefinite resolution
timeline

Was the customer's account debited for the stated transaction? Yes No If “YES”, State STAN

Action taken for resolution

CCO’s Name CCO’s Signature

BSM’s Name BSM’s Signature