Applicant Name

Co - Applicant Name

Bank Name

Branch Name

Bank City

Account Number

Account Type Savings Current Cash Credit Over Draft

9 Digit MICR Codes

DEBIT REFERENCE NO

(loan, cell, phone, policy no. etc)

UPPER LIMIT FOR ECS DEBIT

( IN INR)

BANK/UTILITY NAME

DATE OF NEXT PRESENTMENT: d d m m y y y y

All Signatures as in the Bank Records. All Joint Account holders are required to sign

Effective date of ECS Mandate Cancellation:D D M M Y Y Y Y

Bank Stamp Signature of Authorised Official of the Bank

Name Branch

Designation Date

ECS/March 2007/V 1.0

ELECTRONIC CLEARING SERVICE (Debit Clearing) MANDATE CANCELLATION FORMAuthorization of Customer to remit funds/payments to Standard Chartered Bank (SCB)through Electronic Clearing Service

I/We hereby, authorize SCB and their authorized service providers, to record the cancellation of the ECS Debit Mandate

Account holder/s Name

as in Bank Account

(All Account holders)

PARTICULARS OF DEBIT INSTRUCTION

DECLARATION AND SIGNATURE/S

For use by Customer/Account Holder's Bank

(Form to be filled up in capital letters only)

CUSTOMER'S NAME

(Please attach an original cancelled cheque leaf for this bank account)

PARTICULARS OF BANK ACCOUNT

We hereby certify that the particulars of the customers furnished above are correct as per our records, and we hereby

declare that a copy of this mandate form, duly complete and signed, has been submitted to us

I/We hereby declare that the particulars given above are correct and complete. I/We have read all the terms and

conditions as are applicable for availing of this ECS Debit service and agree to discharge the responsibility expected of

me/us as a participant under the scheme. I/We also hereby authorize our representative carrying this ECS Debit

Mandate Form to get it verified and cancellation recorded by my/our Bank. I/We also undertake to record the cancellation

with the presenting banker/utility company as the case may be. I/We also understand that the cancellation will be effective only

when the presenting banker presents the file with the appropriate debit reference number as mentioned above. I/We understand

First Account

Holder

Second Account

Holder

Third Account

Holder

Fourth Account

Holder