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Electronic Clearing Service (Debit Clearing) Mandate Form Customer's Option to Make Payment though Debit Clearing
Depository Participant Name Bank Name Branch 9 Digit MICR Code Account Type (Saving /Current /Cash Credit) with code Account Number Name of Account Holder Date of Effect Start Date End Date Frequency Purpose Upper Limit for Amount
10
11
13
Others Specify
I/We am/are herewith enclosing a blank cancelled cheque signed by me /us I/We, hereby declare that the particulars given above are correct and complete and express my/our willingness to pay as detailed above through participation in ECS. I/We authorized my/our Bank to honor all such instructions. In the event of my/our bank being unable to debit my/our account, for whatsoever reason, I will pay the amount due to you directly to you. If the transaction is delayed or not effected at all for reason of incomplete or incorrect information, I would not hold the user institution responsible. I /We further authorize that you/your banker ________________________________or their representative, M/s ___________________________ to get this mandate verified / lodged with my/our bank and my/our mandate verification charges (if any) may be charged to my /our account. I will also inform you about any changes in my/our bank account. Date This form has to be signed by BANK ACCOUNT HOLDER as per mode of operation in the Bank
Full Name: Signature of the Account Holders (Signatures required as per mode of Operations)
Enclosed: Cancelled Cheque leaf Verification by Account Holder's Bank _______________________________________________________________________________ We hereby certify that the above account is currently operational and the particulars furnished above are correct as per our record. _______________________________________________________________________________
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