Disbursement Request Form

Date Company

Cluster

Branch

Customer Name

Phone Number

Enter a valid 10-digit phone number.

SM/BM/TM

Gold Weight (gms)

Amount Required

Bank Name

Account No.

Enter a valid account number (9–18 digits).

IFSC Code

Enter a valid 11-character alphanumeric IFSC code.

Documents

Aadhar Card

PAN Card

Pledge Card

Security Cheque

Officer Declaration

I confirm the following:

These funds are being released on the personal guarantee of the Branch Manager and Cluster Manager.
I have physically verified the customer's Aadhar and PAN against the original documents and they match the customer present.
All photos attached (Aadhar, PAN, Pledge Card, Security Cheque) are genuine, unedited, and taken by me during this transaction.
The Pledge Card and Security Cheque are duly signed/filled by the customer.
The gold weight entered has been verified on the company's weighing scale as per policy.
I have double-checked the Account No. and IFSC Code belong to the customer (or an authorized recipient).
The customer has been informed of the loan amount, interest rate, tenure, and applicable charges.
This is not a duplicate, benami, or fraudulent loan request to my knowledge.
I understand that submitting false information may result in disciplinary action and personal liability.

I have read and confirm the above

Please fill in all fields correctly.

Officer Login