Department of Treasuries KHAJANE-I Application Form for NEFT/RTGS Remittances [Bank and Branch Name IAxIS BANK, MARATHAHALLI [BANGALORE] [Challan Creation Date: 16/01/2021 Remitter Details: Name of Applicant: IMOOKAMBIKA Remitter Account No. [909010040208458 Remitter Address: \Chakarasanahalli Village, Kolar Taluk [Contact Number [E-mail ID: Beneficiary Details: [Beneficiary Name [Government Of Karnataka Beneficiary Bank Name [Reserve Bank Of India [Beneficiary Branch: [Bangalore Regional Office Beneficiary Account No. [€RO121085300292796 [Beneficiary Bank's IFSC Code: IRBISOGOKAER |Amount(in figures)(A): [Rs 140000/- Only |Amount(In words)(A): [One Lakh Forty Thousand Only Bank's Charges(B): | Transaction charges and taxes applicable at bank level.) fotal(A+B): DDO Details: [DISTRICT OFFICE (MINERAL), MINES & DDO Office: |GEOLOGY, KOLAR DISTRICE DO Code: 161050 Payment Details: [Enclosed is Cheque No. drawn on my/our account for Rs 140000 favouring Reserve Bank ‘Of India towards the above NEFT/RTGS transactions. OR Kindly debit my account number YES/NO. Lar have read the conditions and agreed to be bound by ern. allan Creation Date: [1670172021 lan Expiry Date : 23/01/2021 of Applicant { NEFT/RTGS Mandate should be presented to Bank within Challan expiry date. (seri ier and taxes applicable at bank level, iii) No change is allowed in the NEFT/RTGS details by the customer or the originat GN ansaction i able to be rejected in case of any change in the NEFDIRTGS desig The (iv) This NEFT/RTGS transaction should reach the destination bank before expiry of challan period. In of delay, the NEFT/RTGS transaction would be returned to the originating account. It would be the ibility of the customer and the originating bank to ensure that the NEFT/RTGS Temittancs the beneficiary account well before the expiry period, € Teaches Scanned with CamScanner[ikank and Branch Name Department of Treasuries KNAIANEAL Application Form for NEFT/RTGS Remittances _Customer Acknowledgement AXIS BANK, MARATHAHALLI [BANGALORE} | [Challan Creation Date AeOTzORT NORE Remitter Details: ae of Applicant IMOOKAMBIKA [Remitter Account Number 109010040208458 tact Number: Beneficiary Details: Bs : [Government Of Kamataka Ben: Account No. [CRO121085300292796 B y Bank's IFSC Code: IRBISOGOKAER Amount (in figures)(A): [Rs 140000/- Only A Tn words)(A): IRs One Lakh Forty Thousand Only Applicable Chanes:(By Total(A=B); DDO Details: [DISTRICT OFFICE (MINERAL), MINES & PPO Office: GEOLOGY, KOLAR DISTRICT. [DDO Code: 161050 Callan Creation Date : 16/01/2021 IChallan Expiry Date : [2370172021 UTR Number: Signature of Remitter: Bank Officials Signature/Seal: HOA Details Of challan: CRO121085300292796 Head Of Recount ‘Sub Purpove Name Purpose Specific10 | Amount 7953-0 102105000 Royalty Qt [Quarry Lease No, [140000 Total Amount 140000 Scanned with CamScanner