Complainant: [name], [mobile], [email], [full postal address]
Entity complained against: [name], branch/location [____]
Entity's complaint no.: [____]   Date I complained: [dd/mm/yyyy]
Entity's reply (date and summary): [____ / no reply received]
Account/card/loan reference: [last 4 digits or reference only]
Transaction date, amount and reference no.: [____]

Facts:
1. [Date]: [what happened]
2. [Date]: [what I did, including the date I complained to the entity]
3. [Date]: [what the entity replied, or that 30 days passed without reply]

Loss or inconvenience: [amount and description]
Relief sought: [what you want the Ombudsman to direct]
Documents attached: [list]