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Electronic Clearing Service (Credit Clearing) (Model Mandate Form)

This document contains a model mandate form for receiving payments through electronic clearing service (credit clearing). The form contains details of Tripti Khusharam's bank account, including the name of the bank and branch, 9-digit code number, IFSC code, account type, account number, and signature of the customer. It also notes that the customer agrees to the terms and conditions of the scheme and that bank officials have verified the details are correct.

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Kundan K
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163 views1 page

Electronic Clearing Service (Credit Clearing) (Model Mandate Form)

This document contains a model mandate form for receiving payments through electronic clearing service (credit clearing). The form contains details of Tripti Khusharam's bank account, including the name of the bank and branch, 9-digit code number, IFSC code, account type, account number, and signature of the customer. It also notes that the customer agrees to the terms and conditions of the scheme and that bank officials have verified the details are correct.

Uploaded by

Kundan K
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Annexure B

Electronic Clearing Service (Credit Clearing)


(Model Mandate Form)
(Investor/Customers's option to receive payment through Credit Clearing Mechanism)
(Scheme Name and the Periodicity of payment)

1. INVESTOR/CUSTOMERS' Name : TRIPTI KHUSHIRAM

2. PARTICULARS OF BANK ACCOUNT

A. BANK NAME : UNITED BANK OF INDIA

B. BRANCH NAME : GOMTINAGAR


ADDRESS : 1/43 VIKAS KHAND GOMTINAGAR
LUCKNOW
TELEPHONE NO. : 05226521082

C. 9 DIGIT CODE NUMBER OF : 226027006


THE BANK & BRANCH
(Appearing on the MICR Cheque issued by the Bank)

IFSC Code of Bank : UTBI0GMT550

D.ACCOUNT TYPE : Saving Account


(S.B Account/Current Account or
Cash Credit with Code 10/11/13

E. LEDGER NO./LEDGER FOLIO NO. :

F. ACCOUNT NUMBER : 1426010020280


(As appearing on the Cheque book)

G. Attached document for verification of Bank particular :

3. DATE OF EFFECT
I hereby declare that the particulars given above are correct and complete of the transaction
is delayed or not effected at all for reasons of incompleten or incorrect information. I would
not hold the user institution responsible. I have read the option invitation letter and agree to
discharge responsibilitybexpected of me as a participant under the scheme.

(..........................)
Date: Signature of the Investor/Customer

Certified that the particulars furnished above are correct as per our records.
(Bank's Stamp)

(..........................)
Date: Signature of the Authorised Official of Bank

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