IA,

aanB-e
lEIl DENf,Bf,NK
(A Govemment of lndia Enterprise)
Trusted Family Bank
B'ffi
(A,Government of lndia Enterprise)
Trusted Family Bank
Branch Name

IFSC
Appl.
Form
ITEM CODE . OSO79

Payment
Mode
RTGS NEFT I
Customer Acknowledgement Slip (Customer Copy)
Application for Customer Funds Transfer under DENA-RTGS / DENA-NEFT FACILITY
:..i
Application Form No. UTR No. Request Date : l.'i

UTR No RemitterDetails(Name): - - ProcessedDate

l'a
?,t . \.J

-
Received Application from
tuc Type# A/c No. #1 O-Savings Bank, 11-Current Account, 1 2-Overdraft,
Mr/Ms1M/s
13-Cash.Credlt, '14-Loan Account, 4O-NRE, 5o-Remittanc6 for Customer Not Having Account in Bank, 51-lndo Nepal Remittance , 52 - Ca,d Payments.

Amount to be remitted Rs. Proof of ldentity No. (for non - customers - tick which ever is applicable):
I
under DENA-RTGS/
DENA-NEFT facility (Passport No. / PAN No. / Driving License No. / Telephone Blll No. / e edificate of identification issued by employer in lndia with details and photograph etc.)

Remittance Charges Rs. ^uu.^-^.

Total Rs.
Tel No. / Mobile No. Email
Amount in Words
Beneficiary Details (Name)

Beneficiary Details :

IFSC : '
A/c Type# A/c No. #10-Savings Bank, 11 -Current Account, 12-Overdraft,
A/c No. :
Name : 13-Cash Credit, 14-Loan Account, 4O-NRE, so-Remittance for Cuslomer Not Having Account in Bank, Sl-lndo Nepal Remitlance, 52 - Card Payments.

Mode of Payment RTGS/NEFT IFSC Code of the Beneficiary Bank / Branch (11 Chars)
I

Debit to account no
Name of the Bank: Branch: City: State:

Beneficiary Address
Cheque No.

& Date Tel No. / Mobile No. Email

Drawn on
Originator of remittance
Rs.
Cash Deposit Sender to Receiver lnformation if Any
(for non-customers) lnwords
Maximum Limit
Amount to be remitted under Rs. Remittance Total Rs.
Rs. 50,000/- DENA.RTGS/DENA.NEFT Charges Rs.
t*{
Transaction Date Amount in Words (Rs.)

Time Mode of Debit to my account no (SB/CA/CC/OD) Cash Deposit

Payment :i
Date ir:l (for non-customers)
RTGS/
NEFT Drawn on (Maximum Limit Rs.50.000/-)

I have read, understood the Terms & Conditions / Procedural Guidelines prescribed and shall be bound by it for th6 transaction originated by me/us.
Signature of Bank official
:'+ i.t
Date : (lft r Time .[',:ilF,ql Applicant's Signature
1
, R.P. - 2,00,000 Forms - 812014
*Terms & *Terms & Conditions Apply-See overleaf
Conditions Apply-See overleaf