ब्यूरो के प्रपत्र

Forms CGB-1 to CGB-5

Five instruments carry a grievance from registration to closure. Two are completed by the citizen; three are issued by the Bureau and copied to the citizen. Each is dated, numbered and entered in the registry.

Instruments: Five
By the citizen: CGB-1, CGB-2
By the Bureau: CGB-3 to CGB-5
Fee: Nil

Register of instruments

प्रपत्रों का रजिस्टर

The specimens below show the form of each instrument. Particulars in brackets are completed for each matter.³

Form	Instrument	Completed by	Signed by	Stage
CGB-1	Grievance Registration	The citizen	The citizen	At the outset
CGB-2	Letter of Authority	The citizen	The citizen	Before anything issues
CGB-3	Representation to Institution	Case Desk	Case Desk	Level 1
CGB-4	Escalation Memorandum	Escalation Desk	Escalation Desk	Each lapse of time
CGB-5	Closure Record	Case Registry	Registrar	On closure

FORM CGB-1

Grievance Registration

शिकायत पंजीकरण

The citizen's statement of the grievance. It may be completed online, or printed, completed by hand, photographed and sent by email.

Completed by: The citizen
Sent to: case@cgb.org.in
Result: Registry Number
Online: Available

Complete online

Citizen Grievance Bureauनागरिक शिकायत ब्यूरो

FORM CGB-1Registry No. ____________
Date ____________

GRIEVANCE REGISTRATION

शिकायत पंजीकरण प्रपत्र

PART A: PARTICULARS OF THE CITIZEN

Full name

Son, daughter or wife of

Email address

Mobile (optional)

Postal address

District

State

Capacity:BorrowerCardholderCo-borrowerGuarantorPolicy holderLegal heirApplicant

PART B: THE RESPONDENT AND THE GRIEVANCE

BankCard issuerNBFCInsurerCentral officeState officeService provider

Name of respondent

Branch or office

Category code

Loan, card (last 4) or policy no.

Amount in dispute, ₹

Statement of the grievance

PART C: EARLIER STEPS AND RELIEF

Complained in writing:YesNoReply:NoneRejectedWithout reasonsPartly resolved

Date of first complaint

Complaint reference

Relief sought

Pending before a court, Ombudsman or Commission:NoYes

PART D: DECLARATION

I declare that the particulars above are true and complete to the best of my knowledge. I consent to their use by the Bureau to assess and pursue this grievance. I understand that no fee is payable at any stage, that the Bureau is not a law firm, and that nothing issues to the respondent until I sign Form CGB-2.

Place

Date

Signature or thumb impression of the citizen

FOR THE CASE REGISTRY

Registry No. allotted

Acknowledged on

FORM CGB-2

Letter of Authority

प्राधिकार पत्र

The citizen's authority for the Bureau to correspond on one matter alone. It permits no receipt of money and no settlement on the citizen's behalf, and is revocable at any time.

Completed by: The citizen
Signed by: The citizen
Sent to: case@cgb.org.in
Scope: One matter

Fill and print

Citizen Grievance Bureauनागरिक शिकायत ब्यूरो

FORM CGB-2Registry No. ____________
Date ____________

LETTER OF AUTHORITY

प्राधिकार पत्र

I, [Name of the citizen], of [Address], being the [capacity] in respect of [account, loan, card or policy] with [name of the institution], authorise the Citizen Grievance Bureau to correspond with that institution, and with any Ombudsman, portal or authority before which the matter may be placed, in the matter registered under Registry No. [Registry No.].

I consent to the disclosure to the Bureau of information relating to that matter. This authority does not permit the Bureau to receive any money, to accept or reject any settlement, or to sign any financial document on my behalf. It remains in force until the matter is closed or until I revoke it in writing.

Place

Date

Signature or thumb impression of the citizen

FORM CGB-3

Representation to Institution

संस्था को अभ्यावेदन

The Bureau's first letter to the institution's designated grievance officer. It states the facts, the provisions engaged and the relief requested, and fixes the date from which the reply is awaited.

Issued by: Case Desk
Sent to: Grievance officer
Copy to: The citizen
Standard: 5 working days

Citizen Grievance Bureauनागरिक शिकायत ब्यूरो

FORM CGB-3Registry No. ____________
Date ____________

REPRESENTATION TO INSTITUTION

संस्था को अभ्यावेदन

To,
The Grievance Redressal Officer,
[Name of the institution], [Branch or office]

Subject: Representation on behalf of [name of the citizen], [account, loan, card or policy reference], Registry No. [Registry No.]

Madam or Sir,

1. The Citizen Grievance Bureau writes under the authority of the citizen named above, executed on Form CGB-2 and annexed to this representation. The citizen is copied on this letter.

2. Facts. [The facts of the grievance, in the order in which they occurred, with dates and references.]

3. Provisions engaged. [The directions, codes and policy clauses that bind the institution in the matter.]

4. Relief requested. [The documents, corrections or actions the citizen requests.]

5. A reasoned written reply is requested within the period fixed by your grievance redressal policy, quoting the Registry Number. The date on which the reply falls due has been entered in the Bureau's registry.

Enclosures: Form CGB-2; copies of documents as listed.
Copy to: the citizen, at the registered email address.

Case Desk
Citizen Grievance Bureau

FORM CGB-4

Escalation Memorandum

आगे बढ़ाने का ज्ञापन

Issued when the period for reply lapses, or when a reply is given without reasons. It annexes the complete record and places the matter before the next answerable authority.

Issued by: Escalation Desk
Sent to: Nodal or Principal NO
Copy to: The citizen
Standard: 2 working days

Citizen Grievance Bureauनागरिक शिकायत ब्यूरो

FORM CGB-4Registry No. ____________
Date ____________

ESCALATION MEMORANDUM

शिकायत आगे बढ़ाने का ज्ञापन

To,
The Nodal Officer or the Principal Nodal Officer,
[Name of the institution]

Subject: Escalation of Registry No. [Registry No.] on lapse of the period for reply

Date	Entry in the registry	Reference
[Date]	Representation (Form CGB-3) received by the institution	[Reference]
[Date]	Reply due under the institution's published policy	[Policy clause]
[Date]	No reply received, or reply received without reasons	[Reference, if any]

1. The period fixed by your institution's own grievance redressal policy has lapsed without a reasoned reply. The matter is accordingly placed before you, with the complete record annexed.

2. A reasoned written reply addressing each point in the representation is requested within the period applicable at this level.

3. Should the matter remain unresolved, it will be placed before the regulator or competent authority under the governing scheme, with this memorandum and the record annexed.

Annexures: Form CGB-2; Form CGB-3; documents as listed; any reply received.
Copy to: the citizen.

Escalation Desk
Citizen Grievance Bureau

FORM CGB-5

Closure Record

समापन अभिलेख

Entered when a matter closes, whether on resolution, a forum's decision, withdrawal or decline. It records the outcome and fixes the date by which the citizen's documents are erased.

Entered by: Case Registry
Signed by: Registrar
Copy to: The citizen
Erasure: Within 30 days

Citizen Grievance Bureauनागरिक शिकायत ब्यूरो

FORM CGB-5Registry No. ____________
Date ____________

CLOSURE RECORD

मामला समापन अभिलेख

Registry No.

Citizen

Respondent

Date of registration

Date of closure

MODE OF CLOSURE

Resolved and accepted by the citizenDecision of the Ombudsman or forumWithdrawn by the citizenDeclined with reasons

Outcome of the matter

Forum and reference, if any

RECORD AND DOCUMENTS

The complete record of the matter has been supplied to the citizen. The citizen's documents held by the Bureau will be erased on or before the date entered below, in accordance with the Citizen's charter.

Record supplied on

Erasure due by

Registrar, Case Registry
Citizen Grievance Bureau

Case Registry

A grievance left unanswered is a grievance not yet registered.