Date: Time:

From,

(Customer Name)

To,

(Merchant Name)

I Mr/Mrs…………………………………………… hereby confirm having authorized a transaction done

with………………………………………………………........... on by my card

number…………………………………………………………………..for payment of Rs……………………. each with the

transaction RRN…………………………………………….

I here by acknowledge that the services for the above payment are fully received, and I will not dispute
the payment with my card issuer in the future for any reasons what so ever.

Cardholder Signature……………………………………….

Cardholder Name……………………………………………..