Direct Debit Form by czemtv


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									Branch: ___________


I hereby request you to make direct debit arrangements on my account as per the following details:

Branch Banking Account Number: _______________________________________________________________

Customer Name: ______________________________________________________________________________

Credit Card Number (s): ________________________________________________________________________

Credit Card Account Title:_______________________________________________________________________

Type of Direct Debit Payment:             Same Party                        Third Party                      Staff

 DD Effective Date:                                            DD Expiry Date:
 (mm/dd/yyyy)                                                  (mm/dd/yyyy)

I hereby authorize Citibank, N.A Pakistan (“Citibank”) to make automatic monthly deductions from my branch banking
Account stated above and pay such deducted proceeds to my Citibank Credit Card account mentioned above in order to
repay the outstanding or a part thereof on the Credit Card / Supplementary Card (s). Citibank is further authorized to
obtain and read copies of the Citibank Credit Card & Supplementary Card(s) monthly statements of account and

                                                                                                                            BB - DDA – VC2- 10 - 09
accordingly effect monthly debits to my above mentioned Citibank Credit Card account.

Under these instructions I will be responsible for ensuring that sufficient funds are available in my branch banking
Account at the time of these debits and in case of deficiency of funds I will remain responsible for the payments along
with any late payment or other financial charges levied on my Citibank Credit card(s).

I understand that while every effort is made to ensure compliance with these Direct Debit Instructions, they are accepted
by Citibank on condition that neither Citibank, nor any of its officers or employees, will be liable in any circumstances
for any loss or damage, direct or indirect or consequential, arising out of any failure to comply or delay in complying
with such instructions, whether due to negligence, or any other cause.

I choose to have the following deduction made from my above branch banking Account:

  The full amount as billed in the applicable Credit Card monthly statement of account.
  Minimum 5% payment (Minimum Rs. 200) of the amount billed in the applicable Credit Card monthly statement
   of account.

_______________________________                   ____________________________              _____________________
Account Holder’s Name                             Signature & Date                          Contact No.

                                               FOR BANK USE ONLY

_____________________________________                      ______________________________________________
 Signature Verified By --- Name /Sign/Stamp                Customer’s Identity Confirmed By --- Name /Sign/Stamp
 (Branch Cash Counter)                                     (Front Desk Walk-In / Branch Staff)

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