F. No.

135
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Bank of Baroda
(Head Office: Mandvi; Baroda)
Branch: ………………………………………

PARTICULARS TO BE SUPPLIED BY THE APPLICANT FOR ADVANCES

I give below the particulars of myself, my family and my Assets & Liabilities as at …………………

1. Nam in Full: …………………………………………………………..Age: ……………………..

2. Father’s/Husband’s Name: ………………………………………………………………………
3. Residential Address:

PERMANENT PRESENT

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………

……………………………………………………… ………………………………………………………

4. Telephone Numbers: Office/Shop: ………………………… Residence: …………………….

5. Occupation/Line of business:
a. If in service
i. Name of Employer: …………………………………………………………….
ii. Address: …………………………………………………………………………
iii. Designation: …………………………………………………………………….
b. If in business/profession:
i. Name/s of the firm/company: ………………………………………………….
ii. And its Address/es: …………………………………………………………….
iii. Line/s of activities: ……………………………………………………………..
iv. Since when established: ………………………………………………………
v. In which capacity he/she is representing: ……………………………………
6. Annual Income: Rs…………………………………………………………………………………
7. PAN (If an Income Tax Assessee): ……………………………………………………………...

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 F. No. 135

8. DETAILS OF ASSETS
a. Details of immovable properties (held in own name/joint name)
i. Nature of properties (Please tick whichever is applicable)
1. Plot of Land
2. Agricultural Land
3. House/Godowns
4. Others
ii. Location:……………………………… Survey/House No.: ………………..
Area/Location: ……………………………………………………………………………
Village/Town: ……………………….. District: …………………………………………
iii. Property in whose name: ……………………………………………………………….
iv. Cost (at the time of purchase): Rs…………………………………………..
v. Present estimated market value of the property/ies: Rs…………………….
vi. Whether encumbered/unencumbered:
Partially encumbered. If encumbered,
Give details viz. with whom,
Consideration & major terms & conditions
b. DETAILS OF MOVABLE PROPERTIES IN MY NAME
i. LIC Policies

Policy No. Date of Sum Branch Annual Premium

Issuance of Assured Name Premium in paid up to
Policy Rs. Rs. what period

ii. SHARES/DEBENTURES ETC.

Name of the Total No. of Certificate Total Whether Current
Company shares held No. Amount fully paid Market Value
A/C No. Rs. (Face (Yes/No) Rs.
Value)

iii. TERM DEPOSITS

FDR/RD/YSJY Date Fvg. Amount Name of Due Date Maturity
A/c No. Rs. Bank & Value
Branch Rs.

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 F. No. 135

FDR/RD/YSJY Date Fvg. Amount Name of Due Date Maturity

A/c No. Rs. Bank & Value
Branch Rs.

iv. INVESTMENTS IN GOVERNMENT SECURITIES LIKE BONDS/NSC ETC.

Bond/Certificate Due Date of Issuing Amount Due Date Maturity
No. Purchase Office/Post Rs. Value
Office Add. Rs.
(including
Mutual
Funds)

c. Details like Reg. No., type & value of:

Vehicle/s owned by me
d. Capital invested in business:
Name of Firm/Company
(As on latest Balance Sheet Date)
e. Full details of other investments, if any
(i.e. Jewellery, Investment in other firm/s etc.)
f. Total of all assets 8(a) to 8(f): Rs………………………………………………………….
9. DETAILS OF LOANS IN INDIVIDUAL NAME/FIRM’S NAME/COMPANY’S NAME
a. Name/s of the bank/other Institution and its branch: ……………………………………...
b. Purpose & amount of loan availed:………………………………………………………….
c. Security & repayment schedule/Rate of Interest: …………………………………………
d. Present balance outstanding: ……………………………………………………………….
e. Liabilities other than to Bank and Fis: ……………………………………………………..
………………………………………………………………………………………………….
10. OTHER DETAILS
Details of personal guarantee given for any
Person/firm. If so, furnish details (i.e. Name of the
Bank/Institution, on whose behalf, amount of
Guarantee, present status of account etc.)

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 F. No. 135

11. PARTICULARS OF
a. LEGAL HEIRS
S. No. Name Relatioship Age Present Address

b. NOMINATION
S. No. Description of Assets Bank/Organization Account Amount (at
(Bank Dep./Co. Dep., Certificate No. present/at
Terminal Benefits) maturity)

In support of my above declaration, I enclose

1. Balance Sheet, Profit & Loss Account, Trading Account, Capital Account (Audite/Un-
audited)
2. Copy of employment certificate with details of salary drawn
3. Copies of agreement/revenue records/society certificates in respect of land/building/flat
owned by me.
4. Copies of Income Tax/Wealth Tax Returns/Assessment Order.

I declare that:

I am/am not (tick as applicable) a Director in a/any Bank. There is no litigation against me or the
firm/company in which I am the Proprietor/a Partner/a Director.

The name of the firm/Company or the names of Partners/Proprietor/Director of the Firm/Company

is not on the caution list of RBI/ECGC.

The Proprietor/Partners/Directors of the firm/Company is/are not the Directors in any Co-
operative Bank.

I also declare that the above information is complete, true and correct.

Enclosures:

Place:

Date: Signature of the Applicant

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