November 24, 2014  |  By  | 

Vision – No Child in India shall be deprived of Education because of hunger. Mission – To feed 5 million underprivileged children by 2020. Dear Sir/ Madam, I would like to sponsor ‘food for education’ for underprivileged children through The Akshaya Patra Foundation. As a t oken of my association with this mission, please accept my application for Recurring Donation with the below stated details. E-mail- Toll Free No. - 1800-425-8622 The Akshaya Patra Foundation H.K. Hill, West of Chord Road, Bangalore – 10, Karnataka, India. Ph: 91-80-23471956, 23578346 Fax: 91-80-23578625 All Donations are exempted from Tax under Section 80G, 80GGA(BB) and 35 AC of Income Tax Act, 1961. Consolidated Tax Exemption certificates will be sent annually to the donors Section 1 - Sponsorship Details Frequency of Sponsorship (Choose one):- Sponsorship Amount :- Other Instructions:- Sponsorship Period :- Date of form Filling D DM MY YY Y Date of First Donation Effect:- Monthly Quarterly Half Yearly Yearly In Digits In Words Years Months Or Till I say Stop MY Section 2 - Payment Details ELECTRONIC CLEARING SERVICE (DEBIT CLEARING) MANDATE FORM I/we _______________________________________ (Full Name/Names) hereby authorize The Akshaya Patra Foundation to communicate to my/our bank to debit my/our following Bank Account every _________________________ by ECS for collection of my recurring donation. Y YY M Particulars of Your Bank Account Bank Name Statutory Declaration I /we hereby declare that the particulars given in this form are correct and express my/our willingness to make payments referred in Section 1 of this form through participation in ECS (Debit Clearing/Direct Debit). If the transaction is delayed or not affected at all for reasons of incompl ete or incorrect information, I/we would not hold The Akshaya Patra Foundation responsible. I/we will also inform The Akshaya Patra Foundation about any changes in my/our bank account. Account Number st 1 Account Holder's Name st 1 Account Holder's Signature nd 2 Account Holder's Signature The details provided in this page should match exactly with the Bank Records. Please fill the details carefully Branch Name Branch City 9 Digit MICR No. nd 2 Account Holder's Name (If Applicable) Savings CurrentCash Credit Account Type Section 3 - Personal Details FIRST NAME Name: TITLE MIDDLE NAME LAST NAME ADDRESS 2 ADDRESS 3 ADDRESS 1 CIT Y PIN CODE STATE COUNTRY Address: Phone: LAND LINE E-mail: Introduced by Signature of Authorized official from Bank (Bank Stamp and Date) Banker's Attestation (For Bank use Only) Certified that the signature of the account holder and the details Of the bank account and its MICR code are correct as per our records and a copy of this form duly completed has been submitted to us. Authorization of the Bank Account Holder (To be signed by the donor) This is to inform that my/our payment towards my/our donation to The Akshaya Patra Foundation shall be made from my/our above mentioned bank account with your bank. I/we authorize the representative of the Foundation to get it verified and executed. st 1 Account Holder's Signature nd 2 Account Holder's Signature (Please Fill the Form in Capitals) Please turn overleaf and read the terms & conditions carefully Or No. of times Pan Card No:- FOR IT EXEMPTION CERTIFICATE 0 5 1 5 2 5 IF APPLICABLE IF APPLICABLE MOBILE CODE

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