PLEASE FILL IN BLOCK LETTERS ONLY
UMRN F O R B A N K U S E O N L Y D D M M Y Y Y Y
Tick() Sponsor Bank Code Utility Code
CREATE INDUSIND BANK
I/We hereby authorize to debit (tick ) SB/CA/CC/SB-NRE/SB-NRO/Other
MODIFY
CANCEL Bank A/c number:
NACH MANDATE INSTRUCTION FORM
with Bank IFSC or MICR
an amount of Rupees F O R B A N K U S E O N LY ` F O R B A N K U S E O N LY
FREQUENCY Mthly Qty H-Yrly As & when presented DEBIT TYPE Fixed Amount Maximum Amount
Reference 1 PRIMARY CREDIT CARD NUMBER Phone No.
OR
Reference 2 F O R B A N K U S E O N LY Email ID
I agree for the debit mandate processing charges by the bank for whom I am authorizing to debit my account as per latest schedule of charges of the bank
PERIOD
From
Signature of 1st Accont Holder Signature of 2st Accont Holder Signature of 3st Accont Holder
To
Or Until Cancelled 1. Name as in bank records 2. Name as in bank records 3. Name as in bank records
- 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 as agreed and signed by me.
- I have understood that I am authorized to cancel/ amend this mandate by appropriately communicating the cancellation/ amendment request to the User entity/ Corporate or the bank where I have authorized the debit.
1) Please sign as per signatures in your Bank Records. All joint account holders are required to sign the NACH mandate.
2) Please enclose a photocopy of a blank cancelled cheque issued by your Bank for verifying the accuracy of the MICR code.
3) IndusInd Bank will notify you on the setup of NACH Mandate facility on your Credit Card account. In the interim, we request you to make payment towards your Credit Card outstanding by
alternative modes.
4) This option will carry forward on renewal/ reissue/ swapping/ upgrade of your Credit Card.
5) Please send the completely filled and duly signed NACH Mandate Form along with a blank cancelled cheque to the following address: IndusInd Bank Ltd. (Credit Card Division), P.O. Box No.
9421, Chakala MIDC, Andheri (East), Mumbai – 400 093
DECLARATION
I hereby express my unconditional consent to debit payment of my credit card dues, referred to above through participation in the NACH of the NPCI of the Reserve Bank of India and hereby
unconditionally and irrevocably authorize IndusInd Bank, to raise the debits on such regular payments as referred to above, against my Bank Account Number as given above.
I hereby declare that the particulars given above are correct and complete and if the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I will not hold
IndusInd Bank responsible.
I agree and understand that my bank shall be informed of these debits as per enclosed letter. I shall advise them of the same and I understand that the instruction cannot be withdrawn/ cancelled
except with the written consent of IndusInd Bank for the payment of the credit card dues. I understand that my bank account will be debited 3 working days prior to the payment due date. I will
ensure availability of funds in my bank account. Verification Charges if levied will be borne by me.
Minimum Amount Due Total Amount Due % of Total Amount
Tick Tick %
for Credit Card for Credit Card Due for Credit Card
PRIMARY CREDIT CARD HOLDER SIGNATURE
PLEASE FILL IN BLOCK LETTERS ONLY
UMRN F O R B A N K U S E O N L Y D D M M Y Y Y Y
Tick() Sponsor Bank Code Utility Code
CREATE INDUSIND BANK
I/We hereby authorize to debit (tick ) SB/CA/CC/SB-NRE/SB-NRO/Other
MODIFY
CANCEL Bank A/c number:
NACH MANDATE INSTRUCTION FORM
with Bank IFSC or MICR
an amount of Rupees F O R B A N K U S E O N LY ` F O R B A N K U S E O N LY
FREQUENCY Mthly Qty H-Yrly As & when presented DEBIT TYPE Fixed Amount Maximum Amount
Reference 1 PRIMARY CREDIT CARD NUMBER Phone No.
OR
Reference 2 F O R B A N K U S E O N LY Email ID
I agree for the debit mandate processing charges by the bank for whom I am authorizing to debit my account as per latest schedule of charges of the bank
PERIOD
From
Signature of 1st Accont Holder Signature of 2st Accont Holder Signature of 3st Accont Holder
To
Or Until Cancelled 1. Name as in bank records 2. Name as in bank records 3. Name as in bank records
- 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 as agreed and signed by me.
- I have understood that I am authorized to cancel/ amend this mandate by appropriately communicating the cancellation/ amendment request to the User entity/ Corporate or the bank where I have authorized the debit.
