Application for Financial Assistance under

Auto Clean Scheme

The Branch M anager

State Bank of India Photo of the
_______________ Applicant

Dear Sir,

I hereby apply for a total financial assistance of Rs. _________ (Rupees _____________
_______________________________________________) from your Bank for the
purpose of retrofitting new CNG / LPG Kits into my auto rickshaw as approved by RTO
authorities. The necessary details are as under:-

Name of the Applicant

Residential Address

Permanent Address

Age : SC/ST OBC GEN

Educational Background
Experience
Saving Bank Account No. Bank Name

Branch
Auto Rickshaw Registration No.
Chassis No. & M ake
Permit No. & Date of expiry
Driving License No. & Date of expiry
Details of Existing Loans on the vehicle, if
any Limit Rs____
Outstanding Amt. Rs. _______
Name of the Financier
CNG / LPG Kit NO. & M ake
Retrofitter name & Telephone No.
Proforma Invoice No. & Date
Proforma Invoice Amount
Repayment Period of proposed Loan
Security Proposed Hypothecation of vehicle:
(The loan will be secured by hypothecation
of vehicle duly fitted with new CNG/ LPG
kit or Group Guarantee) Group Guarnatee of :
-
-
-
Insurance Policy No., Amount & Date
Anticipated M onthly Earnings
M onthly Repayment Towards Existing Loan :

Towards Proposed Loan:

I hereby declare that

The particulars furnished above are to the best of my knowledge true and correct.
The Advance, if guaranteed will be utilized for the purpose for which it is granted.
I will not borrow money from any other bank or any other sources against the
vehicle hypothecated to you.
I undertake to include Bank’s Clause in the Insurance Policy and forward the
copy of the policy to tbe Bank.

Yours faithfully,

(APPLICANT)

Encl.:

1. Proof of residential address of the borrower.

2. Proforma invoice for the equipment to be fitted.
3. Original RC Book
4. Copy of Driving License, Badge, Permit, tax Receipt, Insurance Policy, Fitness
Certificate.
5. Form NO. 29 and 30 duly signed.
For Bank Officials:

Particulars given above are verified

Hypothecations of Vehicle OR

Group Guarantors, if any, are as under

(i)

(ii)

(iii)

Sanctioned Term Loan of Rs. _____

(Rupees _______________________________________________ only) repayable in

_________ monthly installments of Rs. ______________________)

Field Officer M anager (DB) Branch M anager

Control by - 1) Assistant General M anager

(Region ____________)

2) Deputy General M anager

(Zone ______________)