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Appendix - VIII Form No. E-5 Electronic Clearing Service Credit Clearing Model Mandate Form Option to Receive Payments through Credit Clearing Mechanism Authority holding the account Registrar/Fin Officer/Director/Principal/Chairman etc. Particulars of Bank Account A. Bank Name B. Branch Name Address Telephone C. 9-Digit Code Number of The Bank Branch Appearing on the MICR Cheque Issued by the bank D. Account Type S*B. Account/Current Account or Cash Credit with Code 10/11/13 E* Ledger No*/Ledger Folio No* F* Account Number G* IFSC Code No* of the Bank In lieu of the bank certificate to be obtained as under 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. 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 responsibility expected of me as a participant under the Scheme. Date seal ------------------------------- Signature of the Authority with office Certified that the particulars furnished above are correct as per our records. Bank Name B. Branch Name Address Telephone C. 9-Digit Code Number of The Bank Branch Appearing on the MICR Cheque Issued by the bank D. Account Type S*B. Account/Current Account or Cash Credit with Code 10/11/13 E* Ledger No*/Ledger Folio No* F* Account Number G* IFSC Code No* of the Bank In lieu of the bank certificate to be obtained as under 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. Account Type S*B. Account/Current Account or Cash Credit with Code 10/11/13 E* Ledger No*/Ledger Folio No* F* Account Number G* IFSC Code No* of the Bank In lieu of the bank certificate to be obtained as under 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. 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. 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 responsibility expected of me as a participant under the Scheme. I have read the option invitation letter and agree to discharge responsibility expected of me as a participant under the Scheme. Date seal ------------------------------- Signature of the Authority with office Certified that the particulars furnished above are correct as per our records.

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