LCOBANK BANK For SINGLE TRANSACTION ONLY
Itranch ............................. Branch ........" ...............
Form HTGS-l
Distinctive Remittance Number (for RTGS FUNDS TRANSFER APPLICATION CUM PAYMENT ORDER Date ........................·
,Bcr~>~l!3rTm ······r'mrmmr [mil (To be filled in by the Applicant in Block Letters) ..................................
1.Name and Address of th_e_A r-' lp'-'--r-Plli_c_alr-1t_: .----.---.--_, _,-----,---,_--,_........-,,----,-
Date ..........................Time .....................
Rccei ved hom: .........................................
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By Cheque/Transfer for RTGS u"-n":"t -+---I-----II---j- - --. ._. ···· .. -1--1·--+
remittance favouring ............................
rtlI1K._ ...._ . ._ ...............................................
Branch ........................................................... 2. Bank
/\:c 1'.0 .......................................................... ~~~~~----I~r-+-~-+-;--r-+-'_~-+----I'~' ·~--~~--t--+--r~--r-'_-r~--r-'_~
3 Branch 4. City
-4-i--+--1--r..:...;_~L::--:-:------+--l--+--+---+--Ii--+--+---+____;1--+-
CCIIUl. ..........•...................•.............•.... •••••••••••••••••••••• _ •••••••• __ •• - •••••••••• , ••••••• •••••••• ••••••••••••••••••• - •••••••• , •••••••••••••••••••••••••••••••••• 0"
.vmuunt !Z:- ...._ ................................................ ~5~.~S~t~at~e~~----I __ r-+-~-+~ __ i--+-,_~-+ __ j ___________6,IF_S_C __ ~o_·_._4-_ri'-; __ ~~_-+-4_+-~_-4_----I_
7. Account No. 8. Type of A/C
Charge~ H,~ .., ..., ..............., ..., ....., ......
Iota] Rs ..................................................
( Rupees ...................................................... Amount to be remitted Rs.................. Bank Charges (including RBI charges) Rs. ,..... Total Rs .............. ,
........................................................... ) (Rupees .. , ...................." .. , .................................................................................... , ......., ........, ........., ..........., .. , .....only)
'jrNeagreeto th-eterms and conditions printed on the reverse hereof.
l erms 01' remittance are on the reverse. Enclosed Cheque No .........., ................../Debit Authority dt. ......................Rs ............................enclosed.
Customers Signatur
-----_._-----------------------=-=-=--=-:-:-:-:--:;:-:::-;-:-:::-=--:::-:-:-:-:--:---------------------------
FOR BANK'S USE ONLY
Time of receipt .. , .. , ............(AM/PM) Time of receipt .......................(AM/PM)
Applicant's desiqnated NC DEBITED. Entered in the RTGS Re ister Outward
Authorised Signatory Date of Transfer ...........................Transfer Scroll No ..............
Oestn. Bank Br. IFSC No.
SFMS Reference No
Settlement Advice Received (Time)
..........................................................................................
Authorised Signatory (Arv Authorised Signatc
PM)
..............................•.......................................••...••.••....•..........• _ .........•••••.•......•......... _ ••..•••...••. _ •••..•......•...•................... _ .. " ••• _ .••..•..•.. _. __ o _______________________________________________________
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