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Form - 9

Government of Karnataka
Finance Department
Department of Treasuries
MANDATE FORM
Electronic Clearing Service (Credit Clearingy Real Time Gross Settlement RTGS)/ National
Elecronic Fund Transfer (NIEFT) facility for receiving payments.

A. Details of Accounts Holder (Student) : -

Firct Name

Name of Recipient (Students) Second Name :

Last Name

Institution / College

Course & 1", 2"', 3", & 4'" year

Recipient type (Category)

USN Number for 2"o ,3^, & 4' yeat

SSLC Reg. No. for l" year

Aadhaar Number

Voter ID

Complete Institution / College

Address I
Address

Address 2 :

Pin Code :

Students
Mobile Number ofthe Recipient
Parents

E-mail ofthe Recipient

Fa\ Number (lnst./College/Offi ce)

 -2-

.d Bank Account Details of the recipientr

Bank Name

Branch Name

Type of Bank Account (Please Select Savings ! / Current Account E

the 4pe of Bank Accoult) *lr.tinor f] / Maiu E
Account Number (as appearing in the
cheque/Pass book)

9 digit M.I.C.R Code of Bank Brarch

I.I.S.C Code of the Bank

Documents Enclosed f] Photocopy oI the Cheque Leaf issued by bank

f-l Photo copy of the Amount Recent
Tra nsaction(amoun t deposited/with draw
-
I
Zerox of fust page of pass book bearing
Account Number
$ The Student having a Minor Account in the bank cannot be accepted to NEFI
plocess.
* Without Bank transaction cannot be accepted to NEFT proce8s.

Date of Effect :-

I hereby dedare the pafticulars given above aie correct and comPlete. If tlrc
tlnt
tmnsaction is delayed or not effected at all fol reasons of incomplete or incorrect bformation I
would not hold the Institution responsible. I have lead the option invitation letter and agree to
discharge responsibility expected of me as a participaflt under the Scheme.

Date: Signature of Student

ShouV be Veified Bf Case Worker:-

Drte: Signature of Caee worker

Date: dn.ipal Signatule & Seal

Form - 9

Government of Karnataka
Finance Department
Department of Treasuries
MANDATE FORM
Electronic Clearing Service (Credit Clearing)/ Real Time Gross Settlement RTGSy National
Electronic Fund Transfer Q.JEFT) facility for receiving payments.

A. Details of Accounts Holder (College Piincipal) :

Name of the Recipient (Principal) First Name:

Second Name:

Last Name:

hstitution/ Couege

Office

Recipient type (Designation)

Aadhaar Number (P ncipal)

Voter ID (Principal)

PAN Number (Principal)

Provident Fund Number (Principal)

Complete Institution/College office Address Address 1

Address 1

Pin code

Mobile Number of the Recipient SelJ

Office & Residency

E-mail (e-mail of the recipient)

Fax Number(of the Inst/ College Office)

Remarks IF Anv
 B. College Bank Account Detaile of the re.ipientt
Bad< Name

Branch Narne

Type of Bank Account (Please Select Savings! Cwrent Account f]

tlle 9?e of Bank Account)

Account Number (as appearing in the

cheque/Pass book)

9 digit MICR Code oI Bank Blanch

IFSC Code of the Bank

Document Endosed ! Photocopy oI the Cheque Leaf issued by bank

T-l Photo copy of l-he Amount Recenl.
L---.1 | raisaction(anount deposited/ with drdw

zerox or first page or pass book bearing Account Nlmber

I
* Without Bank tranaaction can't be accepted to NEFT plocess.

Date of effectr
I hereby declare that the particula$ given above are correct and complete. If the
Tran6action is delayed or flot eflected at all for leasons of incomplete or incorrect
information I would not hold the Institution respoflsible. I have rcad the option
invitation letter and agree to discharge responEibility expected of me as a pafticipant
under the Scheme.

Date: Seal & Signature of Principal