To AXIS BANK Ltd.

RTGS Transaction Request Form

Customer s Instruction (Please write in block letters)
In Figures Amount to be Remitted Rs. Name Of Applicant Address of Applicant Beneficiary Banks IFSC CODE (Mandatory 11 characters field) Name & Address of Beneficiary Banks Account No. of Beneficiary Name of Beneficiary Address of the Beneficiary Details/Purpose of Payment (Max 140 Characters)

Date:___/____/201

In Words

LAXMI VIDYAPEETH
LAXMI VIDYAPEETH,P.B.No.15,SARIGAM P.O.,TA.UMERGAM DIST. VALSAD

SMT.SHANTABEN HARIBHAI GAJERA CHARITABLE TRUST

Remit less Charges : YES / NO Payment Method (includes amount remitted & AXIS charges) (please as applicable)
Debit Applicant S Account No. Cheque Payment Other (Please Specify )

9 1 0 0 1 0 0 4 7 5 7 8 1 7 0
Cheque No.

Contact No. (0260) 2786661 / 2 / 3 I am / we are aware of the RTGS system launched by Reserve Bank Of India I / we have read the conditions printed overleaf and agree to be bound by them Authorised Signatories 1.________________ 2.________________ 3._______________ For Bank Use Only Signatures Verified Balance Confirmation ALM Reporting (If applicable )

Customer Acknowledgement In Figures

Amount to be Remitted Rs. Name of Beneficiary Debit Applicant Account No.

In Words