KarnatakaGramin Bank

Sponsored by Canara Bank

(A Scheduled Bank, EstdI by Govt.of India,

CUSTOMER REQUEST LETTER

Customers only)
[For Savings &Current A/c (Proprietorship)
To:
From: The Branch Manager
Karnataka Gramin Bank
Brarc

Dear

I/We request you to provide me/us the sevice/s ticked in the box below. Youcar1 debit charges as appicabie to
my account.
My A/e No. LAR GLGoo39 Customer ID
Phone / Mobile No. CquxsKA Emil |D

Kindly update my Permanent acCOunt Number in your reCords: PAN

proof of PAN)
Please tick in the appropriate box.
1, aHEQUE BOOK REQUEST:
a. We have not received Cheque Book for my / our new account. Please issue cheque boo.
b. We have not received personalized Cheque Book.
C. I/We have lost the cheque book requisition slip, Please issue a Cheque Boo.
2.CHEQUE STOP PAYMENT REQUEST:
a. UI/We have lost the Cheque Book
containing leaves from
the same and issue new Cheque Book.
b. /We have issued a Cheque No. for favou,
dated
Please stop payment of he cie,
3. DEPOSIT OF CASH/CLEARING CHEQUE/OUTSTANDING CHEQUE/TRANSFER OF FUNDS:
a.U I/We have remitted cash amounting to at
branch for credit of A/c No
Amount not credited/short credited. Please verify.
b. LJI/We have deposited the Cheque No. amount Date of Deposit
Drawee Bank and Branch
- Credit not received in my/our account. Please verify and credit.
Returned cheque not received. Plese verify and return the cheqUE.
C. UAn amount of remitted on
beneficiary's account. Please verify.
d. LIAn amount of remitted on (date) through RTGS NEFT By
Bank/branch for credit of my/our A/c No. not credited. Please verify arnd credit.
4. |PASS BOOK/PASS SHEET:
a. UPass Book- I/We have not received Pass book for new account. Please isSue pass book.
b. ODuplicate Pass Book- I/We have lost the pass book. Please issue duplicate pass book with enes frum
to
C. DPass Sheet - Please issue dupiicate pass sheet from
Duplicate Pass Sheet - Please issue duplicate pass sheet from
Please register my e-mail address and send the pass sheet -- Weekly Fortniqhtly / PeroC tViy
Bi-monthly /quarterty/Half-yearlylannually.
5.CHANGE OF ADDRESS: I Permanent Address DCommunication Address
a. Pease update the contact information (residence/office) in your records. I/We am/are enclosing proot ot my our
PIN
new address. My/Our new address is City
Tel No. (Mobile No. )E-mail ID

Cut hei e
 6FIXED DEPOSIT / KAMADHENU DEPOSIT I RECURRING DEPOSITS:
Account No Date of Deposit :
Depos1t Receipt not receved months/years.
Tonure of the DenOt wrongly mentioned. Correct Tenure:
kate nterest not correctlv anplied / Preferentlal rate not given.
Fercdicdl FD interest not credited to account /pay order not recelved.
not effected in my SB/CA/FD/KD/RD A/C No.
laionFDnot registered / not cancelled/ variation as requested
I. UPeriodical interest not credited to accOunt /pay order not received
7. TAX DEDUCTION AT SOURCE:
DTDS Certificate Request for the FY
Interest Certificate request for the FY
TOS Cetificate not received for the FY
Tarm 15H/15G retted at branch on but tax deducted.
isnvath n fax deducted and Tax remitted. Please verify.
SIANDING INSTRUCTIONS:
folowing stand1ng instructions not executed:
Instructions date: Amount ?
From : A/c No. Perlodicity
To A/c No.
ACCOUNT MODIFICATION:
ACOunt No.
Name:
ocuments submtted for KYCCompliance. KYC details not
Date of Brth not updated though proof of Date of updated.
Brth submitted On
ConversION of indvidual account into joint account not made.
Status of account not changed from Minor to Major.
Additon / Deleton of Joint Account holder not made.
f
U Mode of operation wrongiy mentioned from the one mentioned in the A/c opening form.
10. DEBIT CARD:
Ihave filled up the fornbut not received the Card. Please check and issue the card
Lost Card - My Debit Card is lost. The 16 digit Card No. is
Dlage hot List the Card. (Please fill up separate appln.form for obtaining new card).
CardexDed. New Card not received.
ATM - Cash not dispensed/partly dispensed- ATM ID transaction date Amount
(Please attach Trarnsaction Sip).
11. INTERNET BANKING/MOBILE BANKING (Strike out which is not applicable)
a. Oihve filed up the form but not yet received the User IDfor Internet Banking/Mobile Banking. Please issue.
My User Profile is blocked. Please unlock.
c. OI have forgotten my User ID and Password for Internet Banking / Mobile Banking, Please reissue.
12. SMS REGISTRATION: MOBILE NO
Modification
Atdition
[eletion.
13. OTHERS (Please specify):

DECLARATION
holding the afore-mentioned account with Karnataka Gramin

and the same may be updated in the bank's records for Mobiie Banking,
sede any comnunkon related wmy above account, as wel as transaction advises. I also authorise the bank to contact me on the above
hentio humber for doing ver ificaton cal backs or checks to confirm the veracity of any transaction, as deemed ft by the bank. I confirm that the
<ad nhle nntber is held by me and is not in use by any other third party and I undertake that Ishall duly and promptiy inform the bank if and
2. 1 ave reai and understood te document contan1ng the "Terms and Conditions" &Disclaimer Clauses" govening Karnataka Gramin Bank's Internet
Bank1ng senvKes avalabe n Bank's Internet Banking portal (htos inetbankina. pragathikrishnabank.com) accessed through Bank's official website
ww aithdy oiRk sam and I accept the same. Further, I also agree that the transaction and the requests exeuted in the above mentioned
acots toh Internet Banking under my user ID and password wl be legally binding on me and I am responsible for maintenance of secrecy and
(onftetality ot the intormaton 0assed on to me
by the Rank throah Internet/Mobile/Mail/Telephone.
XhSt and agree to be bourndby the Ternns and conditions to various products and services incuding ATM Cards, Internet Banking,
as dispheyed an
nnerever oolkabk.
kl y )i availabie at branches. I agree that the Bank may debit dervice charges plus taxes to my account

Signature of the Account Holder/s

Cut here
ACKNOWLEDGEMENT
We acknOwledge having received customer request letter from
requesting for point No
Please affix date seal with time
(full name) A/c
The signature is verified &found correct.
Signature of the Officer / Manager