Annx-II (To be obtained in Triplicate One each to Destination Bank Branch, Home branch which has made the

e advance, Customer) in System: Mandate Ref Number : Date of Entry

Contribution to This Account No: Account Name

ELECTRONIC CLEARING SERVICE (DEBIT CLEARING) MANDATE FORM CUSTOMERS OPTION TO MAKE PAYMENTS THROUGH DEBIT CLEARING

1. Customers Name: 2. Particulars of bank account: a. Bank Name: b. Branch name: c. 9-digit code number of the Bank & Branch appearing on the MICR cheque issued by the Bank (please attach the photocopy of a cheque or a blank cancelled cheque issued by your bank for verify the accuracy of the code number): d. Account type (SB Account/current Account or cash Credit) with code10/11/13: e. Ledger no/ledger folio no. : f. Account No:
as appearing in the cheque book): 3. Date of effect: The Details of the debits to be made and beneficiary are: Beneficiary Purpose of Amount payment
Indian Bank Branch:

No of Years

Start Date

End Date

Contribution

I, here by, declare that the particulars given above are correct and complete. I authorise you to debit my Account and pay the amount to Indian Bank under ECS. 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 the responsibility expected of me as a participant under the scheme.
(.)

Signature of the payer/customer Date: Certified that the particulars furnished above are correct as per our records.

Banks seal: ( ) Date: Name:

SIGNATURE OF THE AUTHORISED/OFFICIAL OF THE BANK Designation: