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Date of Effect 1 5# 10 15 20 25
Frequency : Monthly# Quarterly End Date : MM YYYY
Period Start Date: MM YYYY
MICR No* :
Account Type :
Account
Operation :
--------------------------------------------------------------
Savings
I / We hereby, authorise Aam Aadmi Party through their authorised service providers, to debit my / our following bank account by ECS (Debit Clearing). Utility No. of Aam Aadmi Party is 1109726.
Bank Account Details
Notes:
First /Sole Account Holder* Second Account Holder
Electronic Clearing Service (Debit Clearing) - Mandate Form
Bank's Stamp
Branch :
Single
Current
Joint
* MICR is a 9 digit number printed on the bottom centre of the Cheque leaf.
* Rubber stamps needed in case of companies, partnership firms, proprietorship firms etc and name and designation of the
authorised signatory.
Certification By Account Holder's BankI/We have registered for the RBI's Electronic Clearing Service (Debit Clearing) / Direct Debit / Standing Instruction and that my payment towards Aam Aadmi Party shall be made from my/our below mentioned bank account with your bank. I/We authorise the representative carrying this ECS (Debit Clearing) / Direct Debit / Standing Instruction mandate Form to get it verified & executed. I/We hereby declare that the particulars given above are correct and express my willingness to make payments referred above through participation in ECS ( Debit Clearing) / Direct Debit / Standing Instruction. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect information, I/We would not hold the user institution responsible. i/We will also inform Aam Aadmi Party about any changes in my bank account.
Service Acceptance
I/ We confirm that the particulars given above are correct and complete. I/We hereby authorise my/our bank to debit my/ our
above mentioned account for the amount of payment/s specified by me through this service. The authority shall be in force with
immediate effect and shall continue until I/ we revoke it by instructions delivered to Aam Aadmi Party in writing.
Third Account Holder
Authorisation of Donor to remit funds/payments to Aam Aadmi Party through Electronic Clearing Service
Donor Information
( # denotes Default value )
Donation to Aam Aadmi Party is exempt under section 80GGB/80GGC of the Income Tax Act, 1961.
Aam Aadmi Party accepts donation from an Indian citizen only ( either living in India or abroad - NRIs with valid Indian passport).
Gender :
City/District :
Pin Code :
Email :
Passport No. (for NRI) :
Account No :
Bank Official Name :
Designation : Date :
Name :
Address :
State :
Mobile :
Tel No :
Amount :
First/ Sole Account Holder :
Second/Third Account Holder :
Bank Name :
Branch Name :
Bank City :
Form to be filled in Capital letters only.
Make sure that a signed cancelled cheque is attached with the form.
Once the form is filled and attested by Bank Official, send us to Donation Team, Aam Aadmi Party, A-119, Kaushambi, Ghaziabad,
U.P., India - 201010
For further clarification, call us at +91 9717460029 or email us at [email protected]
Either or Survivor
Authorised Signatory
O/D
Special Instructions
