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Bajaj Finance Limited

Tel +91 20 27472851

Registered Office: Mumbai-Pune Road, Akurdi, Pune 411035. Maharashtra India


Fax +91 20 27406382
www.bajajautofinance.com
Corporate ID No. L65910MH1987PLC042961

2W/3W

Bank

Signature of Account Holder

MANDATE INSTRUCTION FORM

CIN: L65910MH1987PLC042961
Sponsor Bank Code
Tick
CREATE
I/We hereby authorize
MODIFY
Bank a/c number
CANCEL

UMRN

Date

D D

M M

Utility Code
BAJAJ FINANCE LIMITED

With
An amount of Rupees
FREQUENCY

Signature of Joint Account Holder (if any)

To debit (tick )

IFSC

or MICR

X Mthly

X Qtly

X H-Yrly

As & when presented

DEBIT TYPE

Fixed Amount

Reference 1

Phone No.

Reference 2

Email ID

Maximum Amount

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.
PERIOD
Starting from
Upto
Or

D D

M M

Y Y Y Y
Signature Primary account holder

Signature Primary account holder

Signature Primary account holder

Until cancelled
Name as in bank records

1.

Name as in bank records

2.

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 instruction as agreed and signed by me.
I have understood that I am authorised 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

Instruction to fill Mandate:


1.

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.

UMRN is auto generated during mandate creation and is


mandatory to be update during amendment and cancellation of
mandatde. (Maximum length-20 Alpha Numeric Characters)
Date in DD/MM/YYYY format
Sponsor Bank IFSC / MICR code, left padded with zeroes where
necessary. (Maximum length-11 Alpha Numeric Characters)
Utility code of the Service Provider (Maximum length-18 Alpha
Numeric Characters)
Name of Service Provider
Tick on box to select type of action to be initiated.
Tick on box to select type of account to be effected.
Customers legal account number, left padded with zeroes.
(Maximum length-35 Alpha Numeric Characters)
Name of Bank and Branch.
IFSC / MICR code of customer bank. (Maximum length-11 Alpha
Numeric Characters)
Amount payable for service or maximum amount per
transaction that could be processed, in words.
Amount in figures, similar to the amount mentioned in words.
(Maximum length-13 digit Numeric in Paise)
Service Provider generated consumer reference number.

14.
15.
16.
17.

Service Provider generated Scheme / Plan reference number.


Tick on box to select frequency of transaction.
Validity of mandate with dates in DD/MM/YYYY format.
Names of customer/s and signatures as well as seal of
company (where required)
(Maximum length-40 Alpha
Numeric Characters)
18. Undertaking by customer.
19. Permanent ID of customer e.g. PAN/ADHAR NUMBER.
20. Telephone no with STD code of customer.
21. 10 digit mobile number of customer.
22. Mail ID of customer
I have understood that the bank , where I have authorised the \
debit may levy onetime mandate processing charges a mentioned
in their latest schedule of charges published by bank.

Place :
Date:
Signature :

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