Disbursement Request Form

Name of Applicant / Borrower

Application ID / LOS ID
Disbursement Amount Requested
Date by which the Disbursement is required
Loan type

LAN No

DISBURSEMENT REQUEST THROUGH CHEQUE(S)/DRAFT(S) REQUIRED

Cheque/DD in favour of Payee Payable At Bank Name of Payee Savings/Current Bank Account No Amount
of Payee

DISBURSEMENT REQUEST THROUGH RTGS

PARTICULARS CUSTOMER DETAILS

Account Holder Name
Bank Name
Bank Address
Bank Account No.
Bank Account Type
IFSC Code
MICR Code
Customer E-Mail Address
For Official Use
Amount Payable
Application ID / LOS ID
Loan Account No

Signature of Operation

Date Signature of/ Borrower Signature of Co-Borrower(s)