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OxiCash eWallet Top up Issue

Fill this form, if you have tried Topping up your OxiCash eWallet By NetBanking or Electronic Fund Transfer
but the Top up failed due to some reason.

   I (name)

   Email id

   Transfered (amount)

Rs.

   To Top up my OxiCash eWallet

   From my

Bank A/c

   To Oxigen's

Bank A/c (In case of Electronic Fund Transfer)

   On Dated

   With Reference No

   Screenshot of My Bank Statement:

 what is this ?
 
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