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Debit Mandate Authorization Form

The document is a debit authorization form for the Visakhapatnam Cooperative Bank Ltd., allowing the bank to debit a specified amount from the account holder's bank account. It includes details such as the sponsor bank code, account number, and frequency of debits, along with terms regarding mandate processing charges and cancellation rights. The form requires signatures from the account holders and includes fields for personal information and dates.

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manu kiran
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37 views1 page

Debit Mandate Authorization Form

The document is a debit authorization form for the Visakhapatnam Cooperative Bank Ltd., allowing the bank to debit a specified amount from the account holder's bank account. It includes details such as the sponsor bank code, account number, and frequency of debits, along with terms regarding mandate processing charges and cancellation rights. The form requires signatures from the account holders and includes fields for personal information and dates.

Uploaded by

manu kiran
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

The Visakhapatnam UMRN Date D D M M Y Y Y Y

Cooperative Bank Ltd.


(Regd. No. MSCS/CR/1101/2014 ) Utility Code V I S X 0 0 0 0 1 0 0 0 0 2 7 3 6 8  Create Modify Cencel
Sponsor Bank Code IBKL0031VCB I/We authorize THE VISAKHAPATNAM COOPERATIVE BANK LTD.
To debit (tick ) SB / CA / CC / SB-NRE / SB-NRC / OTHER Bank A/c. Number

With Bank IFSC / MICR


an amount of Rupees
Debit Type Fixed Amount  Maximum Amount Frequency  Monthly Quarterly Half-Yearly Yearly As & when presented
Reference 1 Reference 2
1. I agree for the debit of mandate processing charges by the Bank whom I am authorizing to debit my account as per latest schedule of charges of the bank. 2. This is to confirm that the
declaration has been carefully read, understood & made by me/us. I am authorizing the user entity / Corporate to debit my account, based on the instructions is agreed and signed by me.
3. I have understood that I am authorized to cancel / amend this mandate by appropriately communcating the cancellation / amendement request to the user entity / corporate or the bank
where I have authorized the debit.
From D D M M Y Y Y Y

To D D M M Y Y Y Y

Or Until Cancelled Signature of Account Holder Signature of Account Holder Signature of Account Holder
Phone No.
1 . Name as on before records 2 . Name as on before records 3 . Name as on before records

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