Online Payment Intimation Form

Name of the Subscriber:

Address for Communication:

Pincode:

Date Of Remittance:

Payment sent through (Your Bank Name and its branch name):

IFSC Code of your Bank:

Amount remitted:

Bank Reference (UTR/IMPS/UPI) No:

Email:

Phone/Mobile No:

Subscription From:

Subscription Upto:

Contact Person Name: