MANDATE FORM FOR ECS DEBIT CLEARING

Authorisation of Donor to remit funds to Bhumi through Electronic Clearing Service

The Manager, Date:

Bank Name: _______________________________ Branch: _ ________ ________________________

I/We hereby authorise you, to debit my/our bank Account for making payment to Bhumi through (ECS)
Debit clearing as per the details given as under
A. 9-Digit Code Number Of The Bank & Branch |_ | _ | _ | _ | _ | _ | _ | _ | _ |
(Appearing on the MICR cheque issued by the Bank) (OR attach a Cancelled Cheque for reference)
B. Account Type: S.B. Account Current Account Cash Credit
C. Account No | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ | _ |

User ID Date of Effect Periodicity Amount No. of Years Eg:2/3/5 Valid up to

4009117 ___ / ___ / _______ Monthly Rs. _ /- ___ Years ___ / ___ / ______

I/We 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/We would not hold the user institution responsible. I/We have read
all the terms and conditions as are applicable for availing this ECS Debit Service from/through the user institutions and agree
to discharge the responsibility expected of me/us as a participant under the Scheme. I/We also hereby authorize our
representative carrying this ECS Debit Mandate Form to get it verified and executed by my/our Bank. Service charges (if any)
may be debited to my / our account with you. Donor Code | _ | _ | _ | _ | _ | _ | _ | _ |

Signature(s) ……………………………………………………..… Name(s) _______________________________________

Mobile: __________________ Email: ______________________________________________________________

Address: _____________________________________________________________________________________
_____________________________________________________________________________________________
For use by Donor’s Bank: We hereby certify that the particulars of the customers furnished above are correct as per
records and we hereby declare that a copy this Mandate Form, duly complete and signed, has been submitted to us.
(Bank’s Stamp)

(Authorised Signatory of the Bank)

Name: _________________________________
Date: Designation: ______________________________

All contributions to Bhumi are exempt from Income Tax under Sec. 80 G
Our Address: Bhumi, 13/1, Cenotaph Road First Lane, Teynampet, Chennai – 600 018, India.
Phone: 044 4300 9443 | Email: Contribute@Bhumi.org.in