PLACH Direct Debit Mandate - MRA

1 PLACH Direct Debit Mandate Unique Mandate reference - to be inserted by MRAA dditional InformationNIC/NCIDBRNM auritius Revenue Authority Ehram Court, Cnr & Sir Virgil Naz Streets, Port-Louis, Mauritius Helpdesk: +230 2076000 Fax: +230 2118099 Email: Website: D D M M Y Y Y YBy signing this Mandate form, you authorize (a) the Mauritius Revenue Authority to send instructions to your bank to Debit your account and (b) your bank to Debit your account in accordance with the instructions from the Mauritius Revenue Authority. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 3 months from the date on which your account was debited.

2 A person shall be eligible for a refund where (a) the Debit is not authorised, (b) the amount debited differs from the invoice amount or (c) the same instruction is executed more than once. The completed form should be sent to the MRA at the address shown belowYour NameYour addressName and address of your BankYour account numberType of Payment Recurrent PaymentDate of First PaymentDate of Last PaymentApplicable for Recurrent Payments//// D D M M Y Y Y Y D D M M Y Y Y YPlease sign hereSignature/s.

3 Name ..Date//