Debit Authority Letter for post-matric fee reimbursement

Provided by Social Welfare Department

(Mandate to debit the Account)
Name of the Bank..
Customer Name....
Customer Account number..
The Branch Head,
__________________________________________________________________ (Name of the
Bank)
Branch____________________________________________________________ (Name of the
Bank)
Dear Sir,
I irrevocably authorize _____________________________________ (Name of the Bank &
Branch) to
debit my SB Account No. ____________________________by Rs._________________________
only
(Rupees
________________________________________________________________________only)
provided by the State Government as reimbursement of fee under Scheduled Caste/
Scheduled. Tribe
Post-Matric Fee reimbursement Scheme provided by Samaj Kalyan Department &
remits this amount
to_________________________________________________________________________________
(Name
of
the
Institution)
account
No.____________________________________________________
maintained
at_______________________________________________ (Name of the Bank & Branch)
(In case the beneficiary account is with some other Bank)
RTGS/NEFT
(IFSC)
CODE
of
the
beneficiary
Bank
________________________________________
(Name
of
the
Bank
&
Branch)
__________________________________________________________
I / We request you to make the above remittance. It is being understood that the
remittance is to be sent at my/ our risk and my / our responsibility and on the
distinct understanding that no liability whatsoever is to attach to the Bank for any
loss or damage arising or resulting from delay in transmission, delivery or nondelivery of the message or for any mistake. I / We also hereby undertake to refund
to bank any over remittance, which is made by mistake in beneficiarys account. I /
We also understand that remittance would be made as RBI RTGS/NEFT Scheme.

Signature of the Customer

(Name of the Customer)

Date:
Place: