‘FORM B’

COMPLAINT TO OMBUDSMAN

1.	Name of Complainant	:

2.	Address & Contact Details:

3.	Financial institution against whom the Complaint was made 
(Please specify Branch/Office/head Office to which the Complaint was made)

4.	Please Annex a copy of the Complaint you made to the Financial Institution which will give a brief summary of the Complaint and the date etc.

5.	Please briefly state what action/steps were taken by the Financial Institution to settle your Complaint.  If no action/steps were taken, please so indicate.

(i)	I/We certify that I/we have read the Rules/Terms and conditions of the Ombudsman Scheme and we abide by them.
(ii)	I/We agree not to take any legal or any other steps against the Ombudsman and his staff in relation to this Complaint.
(iii)	I/We hereby waive the right to secrecy about my/our account and authorize the Ombudsman to obtain and the financial institution to provide all information about my/our account.

……………………………………………….			………………………………..
Signature of Complainant					Date