Government of Karnataka Finance Department Department of Treasuries MANDATE FORM. Electronic Clearing Service (Credit Clearing)/ Real Time Gross Settlement RTGS)/National Electronic Fund Transfer (NEFT) faclity for receiving payments Details of Accounts Holders:- [Fist Name tn capital ietters), Name of the Recipient banat last Name: tn capital etter) [Aadhar Number IT TTT Trt tT tt address complete Address ladaressz PRNCODE [Mobile Number of the a E-Mail (e-mail ofthe recipient) [B. Bank Account Details oftheredpient- | [| [ [| | | | | | 1 iank Name [branch Name [select the type of Bank [saving Bank current laccount [Account Number as appearing lin the pass book) 9 digit ICR Code of Bank Branch [FSC code ofthe Bank | Date of eect: "hereby declare thatthe particulars given above ae correct and complete. If the transaction is {delayed or not effected a all reasons of incomplete or incorrect information| Weuld nat hold the Department responsible. have read the option invitation letter and agree to discharge responsibility expected of me asa participant under the Scheme, Date: Signature ofthe candidate