Request for Remittance through NEFT / RTGS
(To be filled in by the applicant in BLOCK LETTERS)
Branch:
Request: NEFT RTGS Cheque is mandatory, if request not provided by customer directly.
DETAILS of the APPLICANT (Remitter)
Title of Account: Account No.:
Branch where account is maintained: Type of Account: Savings Current Cash Credit
Mobile Number: Overdraft NRE NRO
Status: Resident Non-Resident Email Id:
DETAILS of BENEFICIARY BANK
Bank Name: Branch:
City: IFSC Code:
DETAILS of BENEFICIARY
Beneficiary Bank Account Name (As per Beneficiary’s Bank record):
Beneficiary Address:
Beneficiary Bank Account Number: Beneficiary Bank Account Number Re-confirmed:
Type of Account: Savings Current Cash Credit Overdraft NRE NRO
Amount to be remitted: ` (in figures) (Rupees in words)
Bank Charges: `
Remark for Remittance: (to be captured)
Remit the amount as per above mentioned details, by debiting my / our account or I/we herewith tender cheque no. dated
for ` /- drawn on our account for the amount of remittance plus your charges.
Rupees in words :
TERMS AND CONDITIONS
I/We abide by the following terms and conditions:
1. It is being understood that the remittance is to be sent at my/our own risk and responsibility and on the distinct understanding that no liability whatsoever is to be attached to the Bank for any loss or damages
arising or resulting from delay in transmission, delivery or non-delivery of the message or for any mistake, exchange or error in transmission or delivery thereof or in deciphering the message for whatsoever
cause or from its misinterpretation when received or the action of the destination Bank or due to RBI (Reserve Bank of India) RTGS / NEFT system not being available or failure of internal communication system
at the recipient bank/branch or incorrect information provided by me/us or any incorrect credit accorded by the recipient bank/branch due to information provided by me/us or any act or event beyond control
or from failure to properly identify the person’s name.
2. I/We understand that the process of RTGS / NEFT request is subject to availability of clear funds in my/our account at the time of processing the request.
3. I/We understand that RTGS / NEFT request submitted after the cut off time will be processed/sent on the next working day.
4. I/We understand that the RTGS / NEFT request is subject to the RBI regulations and guidelines governing the same.
5. I / We agree that the credit will be effected solely on the beneficiary account number information and beneficiary name particulars will not be used for the same.
2855-Ver 1.4-December, 2018 / M024 / Dec 18 / 2.6
Date ________________________________ Signature of account holder/s ______________________________________
FOR BANK USE
Debited Applicant's A/c. Cheque No. & Date
Request Received Date & Time Cheque Amount
Verified cheque details and Signature Yes Request Processed Date & Time
Signature verified by BSOM / BH Yes SDC / Transaction No.
RTGS – UTR No.
NEFT Ref No.
Authorised Signatory (Maker) Authorised Signatory (Checker)
Customer Acknowledgement
Received request for remittance through RTGS / NEFT from Account Number ________________________________ for an amount of ` ________________ vide
cheque number _____________________________ to be credited to _______________________________________ (beneficiary name) in Account Number
________________________________ with _______________________________ Bank bearing IFSC Code ____________________. DCB Bank will accept no
liability for any consequences arising out of erroneous details provided by the Customer / Applicant.
Call DCB 24-Hour Customer Care at Toll Free 1800 209 5363 / 1800 123 5363 or email: [email protected] or visit www.dcbbank.com
DCB Bank Limited Signature of Branch Official with Seal
