To, Date:

The Branch Manager,

Branch

KOTAK BILLPAY REQUEST FORM

Dear Sir / Madam,

I / We having

Customer Relationship Number (CRN) hereby request you to process the BillPay request as mentioned below.

Biller Type Pay Bill AutoPay Delete

Electricity

Amount Entire Bill Biller

(Rs.) Or

*Biller Short name Pay Limit (Rs.) AutoPay

Consumer No.

Process Cycle No. Scheduled

Billing Unit No. Payment

BillPay Requests

Location : (City / State)

Name of the Company

D D M M Y Y Y Y

# Debit Account Number

Telephone

Amount Entire Bill Biller

(Rs.) Or

*Biller Short name Pay Limit (Rs.) AutoPay

Telephone No.

Account No. Scheduled Payment

Name of the Company

Mobile

Amount Entire Bill Biller

(Rs.) Or

*Biller Short name Pay Limit (Rs.) AutoPay

Mobile No.

Account No. Scheduled

Customer Name Payment

Name of the Company

Insurance

Amount Entire Bill Biller

(Rs.) Or

*Biller Short name Pay Limit (Rs.) AutoPay

Policy ID

Client ID Scheduled

Premium Amt. Payment

Name of the Company

Gas

Amount Entire Bill Biller

(Rs.) Or

*Biller Short name Pay Limit (Rs.) AutoPay

Consumer Reference No.

Bill Group No. Scheduled

Billing Unit No. Payment

Name of the Company

Kotak Mahindra Bank

�

ACKNOWLEDGEMENT

Branch Date:

Transaction Reference No. (For Pay Bill only)

ADD BILLER DELETE BILLER PAY BILL VISA CREDIT CARD PAYMENT

ENABLE AUTOPAY DELETE AUTOPAY DELETE SCHEDULED PAYMENT RECHARGE

Customer Name CRN

Account No.

Authorized Signatory Branch Stamp

Visa Credit Card Payment Frequency Biller

Visa Credit Card Amount Monthly Quarterly Half Yearly Yearly AutoPay

*Biller Short name (Rs.) Amount (Rs.)

Visa Card No. Start Date Scheduled

Beneficiary Name

End Date Payment

Senders Name

D D M M Y Y Y Y

D D M M Y Y Y Y

DeclarationI have read and understood the Terms and Conditions relating to Kotak BillPay on www.kotak.com. I accept and agree to be bound by the said Terms and Conditions.

I understand that the Bank may at its absolute discretion, discontinue any of the services completely or partially without any notice to me. I agree that in case of Payment of Bill

and AutoPay the account number mentioned in this form will be debited automatically. Instructions provided in this form will automatically add the specified biller if it is not an

existing biller. Any instruction provided in this form for modification of information pertaining to existing billers will update the existing information of the said biller.

For PAYBILL / AUTOPAY / RECHARGE PLEASE SIGN AS PER MODE OF OPERATION

First Account Holder Second Account Holder Third Account Holder

Biller Type Pay Bill AutoPay Delete

For Branch Use only

Applicants Signature Verified: Yes No

Employee Name:

Employee Code:

Sign:

* Biller short name should be unique for each biller and should not be more than 6 characters# This Account will be debited incase of Pay Bill / AutoPay / Recharge** Mobile No. Field is mandatory incase of DTH, alert will be sent on the mobile no. mentioned.## Nick Name field is mandatory incase of adding a biller.

Others

Amount Entire Bill Biller

(Rs.) Or

*Biller Short name Pay Limit (Rs.) AutoPay

Biller Identifier 1

Biller Identifier 2 Scheduled

Biller Identifier 3 Payment

Name of the Company

RECHARGE

Prepaid Mobile Direct - To - Home (DTH)

Operator Name

** Mobile No:

DTH Subscriber No:

Amount : (Rs.)

Add this to my quickRecharge biller list

##Nick Name

Kotak Mahindra Bank

Biller