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Mandate Form

This document is a mandate form from the Directorate of Agriculture in Goa, intended for beneficiaries to provide their personal and bank account details. It requires information such as the beneficiary's name, contact information, and bank account particulars, along with a declaration of correctness. The form must be certified by an authorized bank official and includes instructions for completion.

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393 views1 page

Mandate Form

This document is a mandate form from the Directorate of Agriculture in Goa, intended for beneficiaries to provide their personal and bank account details. It requires information such as the beneficiary's name, contact information, and bank account particulars, along with a declaration of correctness. The form must be certified by an authorized bank official and includes instructions for completion.

Uploaded by

peaksstore143
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ANNEXURE

DIRECTORATE OF AGRICULTURE
Krishi Bhavan, Tonca, Caranzalem - Goa

MANDATE–FORM

1. Name of the beneficiary : …………………………………………………………………………………………


a. Mobile No/Phone No. of the beneficiary : …………………………………………………………………………………………
b. Address : …………………………………………………………………………………………
2. Particulars of Bank Account : …………………………………………………………………………………………
a) Name of the Bank : …………………………………………………………………………………………
b) Name of the Branch : …………………………………………………………………………………………
c) Address of the Branch : …………………………………………………………………………………………
d) Telephone No of the Branch : …………………………………………………………………………………………
e) 9 digit code No. of the Bank and Branch
as appearing on MICR cheque : …………………………………………………………………………………………
f) IFSC Code (11 digit) of the branch : …………………………………………………………………………………………
g)Type of account : …………………………………………………………………………………………
h) Account No (as appearing on cheque book) : …………………………………………………………………………………………
(In lieu of the bank certificate to be obtained as under, please attach a bank cancelled cheque or
photocopy of the cheque issued by your bank for verification of the above particulars)

I 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 would not hold the user institution
responsible. I agree to discharge the responsibility expected of me as a participant under the scheme

Signature of the beneficiary


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Certified that the particulars furnished above are correct as per Bank records

Bankers stamp

Date: Signature of the authorized


Official of the Bank

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Note: All columns/dates should be filled in block/capital letters

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