Transaction Mode:

Consumer Number :
Citizen Number :
Bill Amount :
Due Date :

Amount in words:____________________________________
Bank Name_________________________________________ Branch Code______________________________
Depositor's Contact No__________________________ Date______________________

Depositor Name Depositor Signature Bank Authorized Signature

======================================================================================

Transaction Mode:

Consumer Number :
Citizen Number :
Bill Amount :
Due Date :

Amount in words:____________________________________
Bank Name_________________________________________ Branch Code______________________________
Depositor's Contact No__________________________ Date______________________

Depositor Name Depositor Signature Bank Authorized Signature

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