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Electronic Clearing Service (Debit Clearing) Mandate Form: Service Provider Utility Code: 4119123

The document is a mandate form for a customer to authorize electronic clearing of loan payments from their bank account. It requests the customer's name and bank account details including the bank name, branch, 9-digit MICR code, account type, number, and the date payments should begin being debited. The customer agrees the information provided is correct and understands any delays or issues with payments due to incorrect details are not the responsibility of the lender. The bank certifies the account details match their records.

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Devin Mori
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Download as DOC, PDF, TXT or read online on Scribd
22 views

Electronic Clearing Service (Debit Clearing) Mandate Form: Service Provider Utility Code: 4119123

The document is a mandate form for a customer to authorize electronic clearing of loan payments from their bank account. It requests the customer's name and bank account details including the bank name, branch, 9-digit MICR code, account type, number, and the date payments should begin being debited. The customer agrees the information provided is correct and understands any delays or issues with payments due to incorrect details are not the responsibility of the lender. The bank certifies the account details match their records.

Uploaded by

Devin Mori
Copyright
© © All Rights Reserved
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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ELECTRONIC CLEARING SERVICE (DEBIT CLEARING)

MANDATE FORM
COSTOMERS ADVICE TO MAKE PAYMENTS THROUGH DEBIT CLEARING
LICHFL LOAN A/C NO.:
PAYMENT OF EMI
1. CUSTOMERS NAME

: __________________________________

2. PARTICULARS OF BANK ACCOUNT


A. BANK NAME

: ____________________________________

B. BRANCH NAME

: ____________________________________

C. 9-DIGIT CODE NUMBER OF THE


BANK & BRANCH
APEARING ON THE MICR CHEQUE ISSUED BY THE BANK
(PLEASE ATTACH THE PHOTOCOPY OF A CHEQUE OR A
BLANK CANCELLEO CHEQUE ISSUED BY YOUR BANK
FOR YERING THE ACCURACY OR THE CODE NUMBER)

D. ACCOUNT TYPE

(S. B. Account / Current Account or Cash Credit)


with code 10 / 11/ 13

____________________________________

E. LEDGER NO. / LEDGER FOLIO NO.

F. ACCOUNT NUMBER
(as appearing on the cheque book)

3. DATE OF EFFECT

____________________________________
____________________________________
_____________________________________

I hereby declare that the particulars given 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 invitation letter and agree to discharge the responsibility expected of me as a participant under the
scheme.

Date: _________________
Place: __________________
A/C no.

Signature of the Customer


Loan
File No.

Certified that the particulars furnished above are correct as per our records.

Banks Stamp:
Date:

Signature of the Authorised / Official


From the Bank.

Service Provider Utility Code : 4119123

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