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Annexure D' Model ECS Mandate Form: Date: Signature of The Authorized Official From The Bank

This document is a model ECS mandate form for customers to receive payments electronically through various payment mechanisms approved by the Reserve Bank of India. The form collects customer details like name, bank account information including bank name, branch, address, telephone, IFSC code, account type and numbers. It also requests the customer to attach a cancelled cheque or bank statement for verification. The customer declares that the information provided is correct and complete and will not hold the institution responsible if transactions fail due to incorrect details. The customer agrees to their responsibilities under the payment scheme. The bank also certifies the details as per their records.

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Dilip Mishra
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3K views

Annexure D' Model ECS Mandate Form: Date: Signature of The Authorized Official From The Bank

This document is a model ECS mandate form for customers to receive payments electronically through various payment mechanisms approved by the Reserve Bank of India. The form collects customer details like name, bank account information including bank name, branch, address, telephone, IFSC code, account type and numbers. It also requests the customer to attach a cancelled cheque or bank statement for verification. The customer declares that the information provided is correct and complete and will not hold the institution responsible if transactions fail due to incorrect details. The customer agrees to their responsibilities under the payment scheme. The bank also certifies the details as per their records.

Uploaded by

Dilip Mishra
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Page 12 of 12

Annexure D
Model ECS Mandate Form
Customers option to receive payments through e-Payment (ECS/ EFT/ DIRECT CREDIT/
RTGS/ NEFT/ Other payment mechanism as approved by RBI.)

Credit Clearing Mechanism

1. Customers name :

2. Particulars of Bank Account

a. Bank name :
b. Branch name :
c. Address :
d. Telephone numbers :
e. IFS code :
f. 9 Digit code number of Bank and Branch appearing on MICR
cheque issued by Bank :
g. Account Type (S.B. Account / Current Account or Cash)
h. Ledger number :
j. Ledger Folio number :
k. Account number as appearing on Cheque Book :

3. Please attach a blank cancelled cheque, or, photocopy of a cheque or
front page of your savings bank passbook issued by your bank for
verification of the above particulars.

4. 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 scheme.

(------------------------------------------------------)

Signature of customer
Date -
Certified that the particulars furnished above are correct as per our records.

Banks Stamp: (.)
Date:

Signature of the Authorized Official from the Bank

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