CBEC e-Payment Request Form

For Branch Use Only

Challan Identification Number (CIN) :

Name of the Designated Officer :
Date: ___________________________ Signature:

Complete Address Details

Full Name:
Phone No/Mobile :______________________
E mail : _______________________________
Payer’s Address :________________________________
______________________________________________
_________________City /District:___________________
State : __________________ Pincode :________________

Tax Payment Details

Full name of Assessee :

Assessee Code :

Accounting Codes Accounting Code Description Amount

1.
2.
3.
4.
5.
6.
(Maximum of 6 Accounting Codes to be accepted)

PAYMENT INSTRUCTIONS

Please debit our Axis Bank Account No.______________________

For an amount of Rs._______________________(Rupees________________

_______________________________________________________________) towards CBEC e-Payment.
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We understand that the Bank will make the CBEC e-Payment on our behalf based on this e-Payment
Request Form submitted by us. We also understand that submission of this e-Payment Request Form does
not imply payment of tax, which is subject to availability of funds in our Axis Bank Account as well as
accessibility of NSDL-EASIEST Website.
We also confirm that discrepancy in the Cyber Receipt, if any, will be brought to the notice of the Bank on
the same day of transaction for any possible rectification on best effort basis.

Contact Number: Authorised Signatory

ACKNOWLEDGEMENT

Received the request for CBEC e-Payment along with Debit Authority for Axis Bank Account
No._____________

for an amount of Rs.___________________(Rupees_________________________________

___________________________________________________________________________)

subject to availability of funds as well as accessibility of NSDL- EASIEST Website.

For Axis Bank Limited