UCO BANK - NEFT/RTGS FUNDS REMITTANCE APPLICATION FORM
Form: Branch: Date: Time:
Beneficiary Details
Name
Account Number
Address
Bank Name & Branch IFS Code
Account Type
Amount (to be remitted) NEFT/RTGS Charges Total Amount
Total Amount in Words:
Applicant Details (Remitter)
Name Account Number
Address
Mobile/Landline No. PAN
Email ID Purpose of Remittance
Please remit the amount as per above details by debiting cash or my/our SB/CA/CC/OTHERS Account No. with branch. I/We agree to the terms and conditions printed on the reverse hereof.
Enclosed Cheque No. / Debit Authority Dated ₹ enclosed.
Reference No
UTR/NEFT Ref No.
Transaction ID
Details of Cash Remitted
₹Pcs₹P.
2000 x
500 x
200 x
100 x
50 x
20 x
10 x
Coins Total

Seal/Signature of Customer/Remitter
 Mobile No.
 PAN
Branch Seal
 Signature of Authorised Signatory
Sign. of Official (Verifying Doc.)
 Sign. of Official (Maker)
 Sign. of Official (Checker)