Service Agreement

THIS AGREEMENT (Agreement) is entered into by the

following parties (Parties) on _________, 2020.

A. ………………………………………, a company
incorporated under the Companies Act, 1956 with (PAN No:
……………..& CIN No: ………………….), having its registered
office at
…………………………………………………………………………
…………………., India represented by its authorized signatory,
Ms. __________________________(hereinafter …………,
which expression shall unless repugnant to the context or
meaning thereof be deemed to mean and include its legal
representatives, successors and permitted assigns); and

B. M/S …………………………….. partnership concern, having

its office at
…………………………………………………………………………
…….., represented by its Partners
,…………………………………………………… a (hereinafter
Service Provider, which expression shall unless repugnant to
the context or meaning thereof be deemed to
mean and include such Service Provider’s heirs, executors, legal
representatives, successors and permitted assigns, as
applicable).
WHEREAS, ............ has obtained authorization from the
Reserve Bank of India (“RBI”) for setting up white-label
automated-teller machines (“WLAs”) in India (per RBI
authorization no. 66/2014 dated 12th February 2014) under
Scheme A contained in the RBI’s circular no DPSS.CO.PD. No.
2298/02.10.002 /2011-2012, captioned “White Label ATMs
(WLAs) in India—Guidelines,” RBI/2011-12/612, dated June 20,
2012 as amended from time to time (“WLA Guidelines”).

AND WHEREAS, ............ has installed and intends to further

install and presently operatesand intends to further operate
certain WLAs in India on the basis of the authorization granted
by RBI as referred to above.

And WHEREAS, Service Provider is an independent agency that

has entered into a contract with ............ to identify, source the
space for installation of ............’s ATMs and other related
equipment, market ............’s
For Service Provider For ............
………….
products and collect cash and load the same into………… WLAs
and has represented to ……….. that it has the ability,
infrastructure, personnel and expertise to pick-up ATM Fit
Currency (as defined hereafter) from the Bankin accordance with
the provisions of this Agreement and load such ATM Fit Currency
provided by the Bank into………… WLAs as specified by ……..
(Services), and has offered to provide said Services to
……….for ……... WLAs on the terms and conditions specified in
this Agreement;

NOW THEREFORE, IN CONSIDERATION OF THE MUTUAL

PROMISES AND COVENANTS CONTAINED HEREIN, THE
SUFFICIENCY WHEREOF IS HEREBY ACKNOWLEDGED,
THE PARTIES AGREE AS FOLLOWS.
1. DEFINITIONS

1.1. In this Agreement, unless the context necessarily requires

otherwise, the following expressions have the meanings given
below. Terms set out in bold, and defined in other provisions of
this Agreement (including the recitals above) have the meanings
given in such other provisions.

(a) ATM Fit Currency means currency notes that are legal
tender in India and that are of only those denominations
that are capable of being loaded into ............’s WLAs, and
which notes are not soiled, mutilated, counterfeit or
demonetised in any way.

(b) Authorized Representative means a person or persons

appointed by each of the parties hereto as its respective
representative(s) for purposes of this Agreement.
(c) Location means the bank branch / currency chest
agreed by ............ from which ATM Fit Currency will be
collected by the Service Provider as stipulated in this
Agreement.

2. OBJECTIVES

2.1. The purpose of this Agreement is to outline the terms and

conditions under which ............, and Service Provider agree to
work with each other. Wherein ............ would deploy the White
Label ATMs, Bank/ currency chestswould supply ATM fit
currency and Service Provider will source the place for setting up
of ATM, maintenance & upkeep of the ATM and pick up the
currency from the bank/ currency chestsand loading of the
currency into ............’s ATMs.
2.2. The Agreement further includes schedules, annexures or
appendices as part of these schedules appended to the
document. These schedules are attached hereto and also form
part of the Agreement.
(a) Schedule A (Scope of Services) – The Services to be
provided by Service provider.
(b) Schedule B (Penalty for Breaches) – Service Levels and
Penalties for the breach of the Service Levels.

For Service Provider For ……………

 (c) Schedule C (fees) – Fees to be paid by ............ to
Service Provider for the services provided by Service
Provider and performance of its obligations.
(d) Schedule D- Service Provider’s Bank Account Details

3. FEES.

3.1. In consideration of Service Provider providing the Services

and performance of its obligations as set out in this agreement,
............ shall pay to Service Provider the fees stated in Schedule
C attached to this Agreement. Notwithstanding anything
contained in the agreement, ............ reserves the right to revise
the fee structure giving one week notice to the service provider.
3.2. All prices agreed between the parties of this Agreement are
prices exclusive of taxes and it shall be the responsibility of each
the party to pay all applicable taxes, levies, duties, charges,
penalties and fees as may become due and payable under the
local state and/or central laws, rules and / or regulations and may
be prevalent and as amended from time to time in relation to the
services received by each party and so included in the invoices
by the party providing the services pursuant to this Agreement.

4. PENALTY

4.1. Service Provider shall be required to pay penalty in the

manner set out in Schedule B of this Agreement.
5. SECURITY DEPOSIT
5.1. The Service provider has paid an amount of
Rs…………..towards an interest free security deposit for due
performance and observance of all the terms and conditions of
this agreement.

6. RIGHTS AND OBLIGATIONS OF SERVICE PROVIDER

6.1. Once the service provider has sourced a site and the same
is approved, ............ would procure the assets and deploy the
ATM at the designated location. Thereafter the Service Provider
shall be responsible for the maintenance and upkeep of the site.
The Service Provider shall use such ............ ATM in the capacity
of a ‘custodian’ of such ATM. It is hereby clarified that the Service
Provider shall at no time / manner become the owner of the said
ATM and shall be required to return the ATM in the same
condition in which the hardware was made available to him within
7 days, at the time of termination/ expiry of this Agreement or at
any time at the sole discretion of ............. ............ shall retain all
right, title, interest and ownership in the ATM Hardware.
6.2. The Service Provider shall not make any type of alteration,
modification, reverse engineering in the ATM Hardware without
prior written permission of .............

For Service Provider For ............

............................
6.3. The Service Provider’s Authorised Representatives shall
collect only ATM Fit Currency and denomination as specified by
............ from Bank/ currency chest, as may be specified by
............ from time to time and such collection shall be conducted
between 8.00am and 5.30pm only on each collection day.Such
collection shall be on all bank working days in the Location.

6.4. The Service Provider shall withdraw currency notes strictly

from the bank account specified in Schedule D on the same day.
The service provider shall ensure that the cash to be loaded in
............ ATMs is withdrawn from the bank account mentioned in
Schedule D and is prohibited to use any other account for this
purpose. Bank charges, if any, incurred for such withdrawal to be
borne by the Service Provider.
6.5. Once the cash is handed over by the Bank to the Service
Provider and is acknowledged by the Service Provider, the safety
and security of the cash handed over will be the sole
responsibility of the Service Provider, until such time as until the
cash is loaded into the designated WLAs and secured, and is
recorded by the WLAs system as having been so loaded and
secured.
6.6. The Service Provider shall have full responsibility for the
management of keys and combinations and passwords of the
ATM and shall be solely and entirely responsible for safety and
security of Cash.
6.7. The Service Provider shall be responsible to ensure that the
cash loaded in ATM is ATM fit currency only.
6.8. The Service Provider shall conduct its business in strict
compliance with all applicable laws, regulations, RBI guidelines
and other statutory requirements.
6.9. The Service Provider shall provide ATM services to ............
only and shall not solicit similar services competing and clashing
with the interest of .............
6.10. The Service Provider agrees that any and all information
concerning the business or affairs of ............, its specifications,
standards, and procedures, together with the Schedules is the
property of ............ and shall always be treated as strictly
confidential.
6.11. The Service Provider shall only designate individuals to be
Specified Personnel after the Service Provider has conducted
reasonable background checks to determine the qualifications
and antecedents of such individuals and has reasonably
determined, including on the basis of the foregoing, that such
individuals are suitable and qualified to be entrusted with the
handling of cash, bank records and similar matters that require a
high level of ethical conduct, trust and professionalism on the
part of the concerned individual.

For Service Provider For ............

............................
6.12. The Service Provider shall keep complete and accurate
records of all the operations and for such periods in connection
with the Services provided pursuant to this Agreement as
required under the applicable RBI Guidelines &Income Tax
Laws.
6.13. Upon reasonable notice, Service Provider shall allow
............ or its representatives the opportunity of inspecting,
examining and auditing the Service Provider’s operations and
business records that are relevant to or connected with the
Services provided pursuant to this Agreement.
7. 6.14. Service Provider shall co-operate with ............ and its
1.
representatives to assure prompt and accurate audit or review of
work done under this agreement. Service Provider shall also co-
operate in good faith with ............ to correct any practices, which
are found to be deficient as a result of any such audit or review
within a reasonable time after the receipt of ............’s audit
report. The cost of such audit or review shall be borne by .............

7. RIGHTS AND OBLIGATIONS OF ............

............’s Authorised Representative shall notify the

Service Provider by e-mail with the details of each ............
WLA to be replenished in accordance with all applicable
RBI notifications issued in this regard.
7.2 ............ shall take at its own cost and maintain for the term
of this agreement the General insurance policies which is
inclusive of money in transit. ............ may require the
Service Provider to submit certain documentation
 maintained by it to ............ in order for ............ to raise an
insurance claim in relation to any policy of insurance
maintained by ............. The Service Provider undertakes
to provide such documentation within two business days
of receiving any request from ............ for such
documentation.
8. Any demand, to make good any loss in case of shortage of
cash or demand to accept unfit cash (where such unfitness
was patent at the time of hand over of the cash) made by
the Service Provider at any time after the Collection
Confirmation has been issued by the Service Provider will
be void and of no effect and will create no obligation or
liability for .............
9. In case of any event like theft/ burglary./
riots/strike/malicious damage/act of god perils damage/
any accident/ incidence etc, the Service Provider shall
immediately inform ............ . The Service Provider shall
lodge an FIR wherever necessary and take necessary
actions to safeguard the ATM Hardware. However, in all
cases, the Service Provider shall keep ............ informed
before taking such actions.

10. REPRESENTATIONS AND WARRANTIES

10.1 Each Party represents and warrants to the others as
follows.

For Service Provider For ............

............................
(a) Such Party has, and for the term of this Agreement will
have, all requisite power and authority to enter into and
perform all its obligations under this Agreement and to
conduct its business as conducted on the date of this
Agreement and as proposed to be conducted by the
Parties pursuant to this Agreement;
(b) Such Party has taken all actions, obtained all regulatory,
corporate and contractual authorizations, and submitted all
notices or filings required to be submitted, for such Party
to validly enter into this Agreement and perform all its
obligations under this Agreement;
(c) The execution and delivery of, or the performance of
obligations under, this Agreement do not violate or conflict
with any statute, rule, regulation, directive or other law,
judgment, order, decree or award applicable to such Party,
or any provision of such Party’s constituent documents, or
any agreement, contract, promise, covenant, undertaking,
representation or warranty, applicable to or made by such
Party;
(d) The Authorised Representatives of such Party are not (and
will not during the term of the Agreement be) persons who
have been charged, at any time, with any crime involving
financial matters, fraud, theft, conversion, cheating or
breach of trust or any similar offence.
(e) This Agreement constitutes legal, valid and binding
obligations on such Party enforceable against such Party
in accordance with its terms; and
(f) Each of the above representations and warranties are
true and correct and shall remain true and correct for the
term of this Agreement.
(g) ............ or its affiliates or representatives have not made
any representations, warranties or commitments relating
to any revenues, profits, investment or expenditure
pursuant to this
agreement.
10.2. Each of the representations and warranties contained in
this Agreement, are separate and independent and shall
not be qualified or limited by any reference to any other
representation or warranty or any other provision of this
Agreement or any prior knowledge on the part of or
attributable to the other Party or its affiliates.

11. TERM AND TERMINATION

11.1. This Agreement shall be effective as on the date of first

cash pick-up or the agreement execution date, whichever
is earlier and shall continue for an initial period of 12
months with an auto renewal, unless terminated in
accordance with the provisions of this Agreement. No fresh
documentation shall be required for such renewed term of
the Agreement.

For Service Provider For ............

11.2. After the initial term, this Agreement shall automatically
renew for additional term of the same period as the initial
term unless any Party delivers a termination notice at least
90 days prior to the end of the then-current term.
11.3. ............ can terminate this agreement by serving one (1)
month written notice to Service Provider.
11.4. The expiration or termination of this Agreement shall not
affect the rights of a Party accrued prior to such
termination.
11.5. The termination or expiration of this Agreement for any
reason shall not terminate the obligation of one Party to
pay any amount due to the other party in respect of all
periods through the date of termination or expiration. In
addition, any terms of this Agreement that by their nature
are intended to survive expiry or termination shall survive
such expiry or termination, including without limitation the
provisions of this clause, provisions requiring a Party to
hold any other Party harmless from any third party claims,
losses, costs or expenses, provisions on arbitration and
jurisdiction.
11.6. Upon the termination of this agreement, the Service
Provider undertakes to immediately discontinue and cease
to use the trade mark, logo and other intellectual property
of ............ and shall immediately hand over any or all
copies or documentation of such intellectual property.
11.7. Notwithstanding anything contained in the agreement, an
amount of Rs. …………… would be deducted from the
Service provider’s Security Deposit in case he wishes to
 relocate / exit from an ATM site or terminate the agreement
before completing a tenure of 3 years.

12. MISCELLANEOUS
12.1. All notices under this Agreement shall be in writing and
shall be deemed given when personally delivered or sent
by confirmed electronic mail to
………………………………….for ............ Payments and
………………………………………….. for Service Provider,
or upon the date of confirmed receipt or delivery where
sent by prepaid certified or registered mail or internationally
recognized courier to the address of the Party to be
notified, as set forth herein or such other address as such
Party last provided to the other by written notice.
12.2. No failure or delay by a Party to enforce its rights under
this Agreement or to insist on the performance of any
obligation by any other Party at any time or for any period
shall be construed as a waiver of such rights by such Party
or a release of such obligation. A waiver of any right, term
or condition, may only occur in writing if signed by the Party
expressly waiving such right, term or condition.
12.3. In the event that any provision of this Agreement shall
be determined to be illegal or unenforceable, that provision
will be limited or eliminated to the minimum extent
necessary

For Service Provider For ............

............................
 so that this Agreement shall otherwise remain in full force
and effect and enforceable. Provided that in the event of
any change prescribed by the RBI affecting the operation
of this Agreement or the performance by any Party of
obligations hereunder, the provisions of this Agreement
shall be deemed to have been automatically amended
such that such change prescribed by the RBI is
incorporated into the provisions hereof. Without prejudice
to the generality of the foregoing, in the event of any
conflict between the provisions of this Agreement and any
regulations, directions or notifications issued by the RBI in
relation to the subject matter hereof, the provisions of such
RBI regulations, directions or notifications shall prevail.
12.4. This Agreement will be governed by and construed in
accordance with laws of India, and subject to the following
provisions on arbitration, any disputes relating this
Agreement will be subject to the exclusive jurisdiction of
the courts in Bangalore, Karnataka. Any dispute, claim,
difference or controversy arising out of or in connection
with this Agreement, including any question regarding its
existence, operation, termination, validity or breach thereof
shall be referred to and finally resolved by arbitration in
accordance with the provisions of the Arbitration &
Conciliation Act, 1996, and such arbitration shall be
conducted by the Indian Institute of Arbitration & Mediation,
in accordance with its Arbitration Rules (i.e., the IIAM
 Arbitration Rules) for the time being in force. The number
of arbitrators shall be one. The place of arbitration shall be
Bangalore, and the language of the arbitration shall be
English.
12.5. Each of the Parties to this Agreement are independent
contractors and no Party shall be construed as a principal,
agent, trustee, employer, employee or joint venture partner
of any other Party hereunder. In no event shall a Party be
liable to any other Party for any act or omission attributable
to either of the other Parties. In no event shall any Party be
liable to any other Party for any indirect, special or
consequential damages.
12.6. No modification, alteration or amendment of this
Agreement or any of its terms or provisions shall be valid
or legally binding on the parties, unless made in writing and
duly executed by or on behalf of all the Parties.
12.7. Except as expressly provided herein (including with
regard to replacement of the Service Provider) no Party
may assign any rights under this Agreement or transfer any
obligations under this Agreement to any other person,
unless it obtains the prior written consent of the other Party.
Any purported assignment of rights in violation of or
contrary to this clause is void. Provided that nothing in the
preceding sentence shall affect any assignment of rights
approved by a court of law pursuant to and in connection
with the merger or similar
For Service Provider For ............
............................
 arrangement affecting the Party concerned. No provision
of this Agreement shall be construed against a Party on
the ground that it drafted or its agents drafted such
provision.

Intending to be bound, the Parties, through their respective

authorized representatives have signed this Agreement on the
dates written below.

Signed by Ms. _______,

authorized signatory of )
............ )
Date: )
Email ID:

Signed by
______________, )
authorized
)
signatory of Service
Provider )
Date:
Email Id:
For Service Provider For ............
............................
 SCHEDULE A
SCOPE OF SERVICES
The scope of work would include the following activities:
1. Site Sourcing:

a. Acquisition of sites in the town and locality as decided

by ............ and includes the following activities:

i) Collection of the documents from the prospective

landlords/ shops to confirm the title ownership of
the site. (List of documents as given in annexure
1(a));
ii) Coordinating for execution of the rental agreement
between the landlord and ............
iii) In case of termination of sites, to facilitate amicable
closure with the Landlord and supporting retrieval
of the Company’s assets from the site;

b. Site Up-keep (including rent payments); Repair and First

level maintenance;
i. Cleaning up of the site twice a day;
ii. Repair and maintenance, This will be reimbursed on
submission of actual bills as per the rate card shared
by ............
iii. Ensuring the statutory stickers/ papers are displayed
as per the rule;
iv. Arrange for an electrician in case of small electrical
work or any other maintenance work to be
undertaken;
v. Payment of rents to the landlord
c. Conducting marketing activities for enhancement of the
transaction as and when requested by the Company.
1.1. Ensure local arrangement for launch of the site
d. To ensure that efficient manpower as per the requirements of
............ is recruited and all the ATMs within the territory and
scope of the Service Provider are personally visited by the
Service Provider at least once a month to ensure the best in
class service levels.
e. To ensure that all the consumer schemes are timely placed
into the ATMs as per the conditions laid down for the same
by .............
f. To ensure that the MIS and Reports are daily updated by
ATM & are shared next day morning to the designated email
address for review.

For Service Provider For ............

............................
Annexure 1(a):
Collection of all the below legal documents as per company
norms:

A. Registered Title deed / Sales deed / Khatha Certificate;

B. Copies of Records of Rights / Mutation Entries /
Property register cards / Index II register as applicable
C. Notarized NOC from the society/builder/other authorities
for leasing the premises wherever applicable
D. Copies of the last paid Electricity charges, municipal tax
E. Bank account details : Bank, Branch, IFSC Code,
Account Number, Account Name
F. PAN Card
G. Legal heir certificate(in case of the demise of the owner)
and NOC from the other claimant/s
H. Other related documents as required by ............’s Legal
Team.

2. Franchisee Marketing
The Service Provider shall promote the business and arrange
for promotion/ marketing of products and services within the
area specified by ............. However, the material used for
promotion of business is required to be pre-approved by
............

3. Cash Sourcing -
a. To be carried out as explained under rights and
obligations of the service provider of this Agreement. The
Service Provider shall ensure that the personnel deputed to
 collect cash are duly deputed as Authorised Representatives
of the Service Provider for purposes of this Agreement
4. FLM-
a. The Service Provider shall conduct First Line
Maintenance Services on each ATM as required or requested
by ............ (or its agents or representatives) from time to time
which would include but not be limited to Currency Jam,
Dispenser Failure, Cassette type I and II failure, CP & JP rolls
exhaustion, Purge bin overflow, customer receipt failure &
replacement of ribbon. Adequate technical training would be
provided to the Service Provider and its employees to handle
the FM Calls.
b. In case, the ATM has been already cash loaded for the
day, the same will be attended to on best effort on the same
day if the request has been received between 8am and 5 pm.
In case of request received post 6pm, the Franchisee will have
the option to attend the same on or before the next

For Service Provider For ............

............................
 day loading of the ATM. In the event loading is not planned
for the ATM, the Franchisee will have to attend to the call on
the next day without fail.
5. Cash Replenishment-

a. Cash will be withdrawn as per the indent provided by

............. Service provider to ensure that cash is available at
the bank branch as per the amount and denomination
specified in the indent and then send the fund transfer request
to ............. The Service Provider will only pick such amount as
specified in the indent and in case of deviation will intimate
............ while the withdrawal in such case will be changed and
new indent will be sent by .............
b. In case the transferred amount is not withdrawn on any
given day, interest cost to be borne by the Service Provider
@ 10% p.a.
c. The Service Provider or their specified personnel should
carry currency for loading in ............ ATMs in teams of 2or
more persons each.
d. None of the teams of the Service Provider, at any point of
time shall transport currency over and above ………….. Lakhs
to be loaded into ATM. Any loss, if any, incurred due to non-
compliance to the clause will have to be borne by the Service
Provider.
e. On reaching the ATM Premises, the Specified Personnel
shall replenish the Cash in front of the Camera placed in the
ATM Premises. He must ensure that this activity of
replenishment through sorting machine is clearly visible and
facing the camera for recording.
 f. At the end of each day the Service Provider shall conduct
the following procedures: (a) Provide ............ in obtaining the
cash balance report for all ATMs; and (b) provide all reports
and details as required by .............
g. Service Provider to provide withdrawal slips/ bank
statement (in pdf or jpeg format only), of the account
mentioned in the agreement and used for cash withdrawal on
a weekly basis, highlighting the cash withdrawal entries in the
bank statement every Monday for validation at -
-----------------------------------. In case of failure to deposit such
withdrawal slips/ bank statement, further transfers to the
Service Provider’s account will be kept on hold until the
withdrawal slips/ bank statement is submitted and validated.
h. In case of mismatch between the amount transferred to
the Service Provider’s account and
the withdrawals made by the Service Provider, further
transfers will be kept on hold till the same is reconciled.
i. Cash loaded in the ATMs must only be the cash which is
sourced from the Bank. Any other cash loaded into the ATMs,
will be considered as the breach of agreement and can lead
to termination of the agreement and legal actions.

For Service Provider For ............

............................
 j. To service the financial requirements on holidays or
extended weekends, ............ shall, as and when required,
collect an undated cheque as security from the Service
Provider in lieu of any additional exposure provided over and
above the security deposit/ Performance Bank Guarantee
given by the Service Provider. The undated cheque collected
in pursuance to this provision will be presented at the bank in
case the Service Provider fails to nullify the additional
exposure by the next working day.
k. Only authorized FSE should operate the ATMs.
l. Denominations issues will be Rs. 100/-, Rs.200/-, Rs.
500/- or Rs. 2,000/-. No Old High Denominations (OHD) is to
be withdrawn or loaded in the ATMs
m. Authorized FSE’s will carry and display a Government
Identity Proof which was provided in the

6. Physical Verification Audit Support

7. OTC lock management (as and when required)

For Service Provider For ............
............................
 SCHEDULE B
PENALTIES
1. ............ agrees for transition period to the service provider,
the first ninety (90) days following execution of this
agreement, Service Provider initiates steps to ramp up
services as required in this agreement. In this Transition
period, no penalties will be levied on the service provider.
2. In case there is a delay in attending an FLM Call, a
penalty of Rs. 60 per ATM per instance would be charged.
3. Penalty of Rs. 100 would be levied on the Service
Provider in case of failure to provide Cash balancing
report as per the agreed timelines.
4. In the event of any damage/ loss of ATM parts due to his
mishandling/negligence, the actual cost of replacement
would be recovered from the service provider.
5. In case wrong denomination currency is loaded or if there
is a shortage in the ATMs, then the full shortage amount
would be recovered from the service provider.
6. In the event that an ATM becomes cash out due to
negligence of the Service Provider, Rs. 200 per incident
per ATM would be charged.
For Service Provider For ............
............................
 SCHEDULE C
Fees
Payout Grid
Rs…
1st 65 CT .. 1st 35 Non CT Rs…
Rs…
Post 65 CT .. Post 35 Non CT Rs…
* CT- Cash Transaction

1. Payment of electricity charges of the ATM Sites would

be ............’s responsibility.
2. The aforesaid amounts are inclusive of rentals.
Hence the rentals would be deducted and paid
directly to the landlord.
For Service Provider For ............
............................
 SCHEDULE D

Partner Name: __________________________________ (As

per Agreement)
PAN No: ______________________________

Bank Bank Bank Account

Account 1 Account 2 3

Income Cash Cash

Account Type Payout Withdrawal Withdrawal
(Income/
Cash
Withdrawal)

Beneficiary
Name ( as
per bank’s
record)

Bank Name

Branch Name

Account
Number

Account Type
(SB/ Current/
OD etc)
Note: Only
Current
Account to be
opened
for cash
withdrawal
purposes)

IFSC Code
 Account
(Existing/
New)

Declaration
1) I, _________________________________________
(Authorised Signatory) of the firm
__________________________________________________
_________ do hereby declare and confirm that the aforesaid
account number _____________________________________
&
___________________________________marked for "Cash
withdrawal" for ATM Cash replenishment would be used
exclusively for ATM operations of ............ .............................
This account would not be used for any other purpose.
2)Further, I/we have ensured that Bank has exempted the
aforesaid accounts marked under "Cash withdrawal" from
applicability of 2% TDS u/s 194N as per the latest notification
from the Ministry of Finance.
3) I/We undertake to submit the bank statements of the
accounts marked under "Cash withdrawal" every 15 days to
the company i.e., ............ Payments
For Service Provider For ............
............................
I understand that TDS, if any, deducted by bank from the
aforesaid bank accounts would be under my / our PAN and the
TDS amount would not berecoverable from the company (i.e.,
............ Payments).
(Firm Name): ________________________________
(Authorised Signatory Name):
____________________________
(Designation: Proprietor/ Partner etc): ____________________
(Signature with date):
__________________________________
For Service Provider For ............
............................