FORM NO.

E-5 Appendix – VIII

MODEL MANDATE FORM
ELECTRONIC CLEARING SERVICE (DEBIT CLEARING)
The Manager
Copy to the User Company
ING Vysya Bank Ltd
Name __________________________
(Branch Name) _________________________
Address __________________________
(Address) __________________________
__________________________
__________________________
__________________________

I hereby authorize you to debit my account for making payment to

____________________________________________ (User Co.Name) through ECS (Debit)
clearing as per the details given as under.

A. 9-DIGIT CODE NUMBER OF THE BANK & BRANCH:

(Appearing on the MICR cheque issued by the bank)

B. Name of the Customer : ___________________________________________

C. Account Number – 12 Digits

Name of Date of Effect Periodicity Amount of Number of Installments/

the (M/BiM/Qtly/etc Installment/Amt of Valid Upto (in case of
Scheme Bill with Upper Limit Utility bills)

D. DATE OF EFFECT : ____________________________

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

Date : _________ Signature of Customer: _________________________ _____

(Note: Please affix rubber stamp in case of companies, proprietorships, partnerships etc)

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

(Bank’s Stamp)
Date: Signature of the Authorized official from the Bank ________________________

(Note:- Mandate to be obtained in 3 copies, Original for Bank, One for User Co and other for
customer)