Model Mandate Form
(Investor/customer's option to receive payments through Credit Clearing Mechanism)
Name of the Scheme and the periodicity of payment

No.

1. Investor/customer's name:

2. Particulars of Bank account

A Name of the Bank :

B Name of the branch :

Address :

Telephone No. :

C 9-Digit code number of the bank and branch
appearing on the MICR cheque issued by the bank:

D Type of the account (S.B., Current or Cash Credit ) with code (10/11/13)

E Ledger and Ledger folio number:

F Account number (as appearing on the cheque book)

3. 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.

(.....................................)

Signature of the Investor/Customer

Date

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

Bank's Stamp

Date:(.................................)

Signature of the authorised official of the Bank