ELECTRONIC CLEARING SYSTEM (DERIT) CUSTOMER'S MANDATE FORM, THE MANAGER PUNE Bank. Branch. I hereby authorize you to debit my account for making payment to HDFC LTD through €CS(Debit) clearing as per details given under. ‘A. PARTICULARS OF MY BANK ACCOUNT. Account holder Name (As pertank account) Bank Name Branch.. MICR Code (Appearing on cheque) Account Number Account Type(Specify) a (S8.CA.CC.NRO.NRE. ete) }. MANDATE DETAILS. USER NAME : HDFCLTD. UTILITY CODE: 4119219 Home loan account No. Maximum Amount (Should be twice the Standard EMI) * Date of Effect(10°/25" ) Year. End Date Day. a (This is current end date could vary with change in repayment schedule.) Periodicity of Payment: Monthly C. CONTACT DETAILS. Landline No, Mobile No. hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for the reasons of incomplete or incorrect information ,I would not hold the user institution responsible. | here by authorize my Bank (as mentioned above) to debit my above mentioned account with the amount of installment & | agree to discharge the responsibility expected of me as a participant under the scheme. Date: ‘Signature of Customer “Provision for change in Repayment schedule of the loan \CERTIFIED THAT BANK PARTICULARS FURNISHED ABOVE ARE CORRECT AS PER OUR RECORDS, Date: Bank's Stamp. Signature of Bank official Note: Kindly attach a blank cancelled cheque with this mandate form. Mandate to be obtained in 3 copies. One copy each for Bank,Customer,HDFC LTD.