CGHS: Mandate Form for Individuals for ECS Facility for receiving Payment

MANDATE FORM FOR INDIVIDUALS

Electronic Clearing Service (Credit Clearing/Real Time Gross Settlements (RTGS) Facility for Receiving Payment

A. Details of Account Holder

1.	Name of the Account Holder
2.	Complete contact address
3.	Telephone number/fax/email

B. Bank Account Details:

1.	Bank Name
2.	Branch name with complete address, telephone number and email
3.	Whether branch is computerized
4.	Whether the branch is RTGS enabled. If yes, what is the IFSC code?
5.	Is the branch also NEFT enabled
6.	Type of bank account (SB, Current/Cash credit)
7.	Complete bank account number (latest)
8.	MICR code of the bank

Date of Effect-

I hereby declare that the particulars given are correct and complete. If the transaction is delayed, or not effected at all for reasons of incomplete or incorrect information, I would not hold the user institution responsible. I have the read option invitation letter and agree to discharge responsibility expected of me as a participant under the Scheme.

Signature of Customer

Certified that the particulars furnished above are correct as per records.
(Bank Stamp)

Dated:-……………..

Signature of the Authorized officer from the Bank

1. Please attach a photocopy of cheque along with the verification obtained from the Bank.
2. in case your Bank Branch is presently not , “RTGS enabled” then upon up gradation to RTGS Enabled” branch. Please submit the information again in the above proforma to the Department at the earliest.

Source : https://cghs.gov.in/showfile.php?lid=5341