Person on whose behalf
payment is made
Name of the Debtor Reference Party: If you are making a payment in respect of an arrangement between the Creditor and another
person (e.g. where you are paying the other person’s bill) please write the other person’s name here. If you are paying on your own
behalf, leave blank.
Party on whose behalf the
Creditor collects the payment
Name of the Creditor Reference Party: Creditor must complete this section if collecting payment on behalf of another party.
Debtor indentication code
For business users: write any code number here which you wish to have quoted by your bank.
Identication code of the Debtor Reference Party
Identication code of the Creditor Reference Party
In respect of the contract
Identication number of the underlying contract
Description of contract
Details regarding the underlying relationship between the Creditor and the Debtor – for information purposes only.