‘FORM A’

FORMS FOR COMPLAINTS

‘FORM A’ (To be used for complaints to 
Financial Institutions/Branch/Head Office)

FINANCIAL OMBUDSMAN, SRI LANKA

1.	Name of Complainant:  (Here insert your Full Name)

2.	Address:  (Insert your Address)

Telephone No. etc.:

3.	Financial Institutions to which complaint is made/Branch/Head Office:

4.	Please briefly state the nature of the complaint.  Please also give any Reference Number used by the Institution in the transaction concerned.

5.	If you have got any documents to support your complaint, please briefly specify them (DO NOT SUBMIT ANY originals with the complaint)

6.	Please suggest what you want done or how you want your 
complaint settled.

7.	Please state whether there is any officer at the Financial Institution that knows or should know about your complaint.  If so, please give his name and any other details.

8.	Any other Remarks/Suggestions you wish to make that the Institution can take into consideration when examining your complaint.

(i)	I/We have read the Booklet/Brochure issued by the Financial Institution on the Ombudsman Scheme.
(ii)	I/We agree to abide by the Rules, Terms and Conditions of the Financial Ombudsman Scheme.
(iii)	I/We have kept a copy of this complaint.  (Please do not fail to keep with you a copy of the complaint).

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Signature of Complainant						        Date