MANDATE FORM
ELECTRONICS CLEARING SERVICE (CREDIT CLEARING)/REAL TIME GROSS SETTLEMENT
(RTGS) FACILITY FOR RECEIVING PAYMENTS.
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A. DETAILS OF ACCOUNT HOLDER:-
NAME OF ACCOUNT HOLDER
COMPLETE CONTACT ADDRESS
TELEPHONE NUMBER/FAX/E MAIL
B. BANK ACCOUNT DETAILS:-
BANK NAME
BRANCH NAME WITH COMPLETE ADDRESS,
TELEPHONE NUMBER AND EMAIL
WHETHER THE BRANCH IS COMPUTERISED?
WHETHER THE NRANCH IS RTGS ENABLED? IF YES,
THEN WHAT IS THE BRANCH IFSC CODE
IS THE BRANCH ALSO NEFT ENABLED?
TYPE OF BANK ACCOUNT(SB/CURRENT/CASH CREDIT)
COMPLETE BANK ACCOUNT NUMBER(LATEST)
MICR CODE OF BANK
DATE OF EFFECT:
I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not
effected at all for reasons of incomplete or incorrect information I would not hold the user institution responsible. I
have read the option invitation letter and agree to discharge responsibility expected of me as a participant under the
Scheme.
(……….……………………………….)
Signature of Customer
Date:
Certified that the particulars furnished above are correct as per our records.
(Bank’s Stamp)
(………….…………………………….)
Signature of Customer
Date :
1. Please attach a photocopy of cheque along with the verification obtained from the bank.
2. In case your Bank Branch is presently not “RTGS enabled”, then upon its up gradation to
“RTGS Enabled” branch, please submit the information again in the above proforma to the
Department at earliest.
COMPILED INFORMATION PROVIDED BY DDOs
Name of the Office:
S. Name & Designation of Name of Bank & Bank Indian Financial
No. Govt. Servant Branch with full Accounts Service code
address Number Number of Bank
Branch
