Piz Affi Application form for Agricultural Credit Praogrgh (Production Credit | Crop loans | KCC | Agri-Term Loan) Application No.... eat. Dear Sir, \/we hereby apply fora oan loans aggregating Rs. (Rupees only) and furnish below the necessary information ‘ype of loan facility 7 Scheme ‘Amount (Rs) a) b) o) TOTAL GENERAL INFORMATION 1. Details of Applicant: Full name of the applicant (s) ‘Age | Education | Village Taluka/ Block/ PO. District 1_| ShrvSmt S/DW of, 2_| ShrvSmt S/DIW of 2. Details of family members: S.No._[ Name of the family members Relationship Whether dependent [ Annual income (Rs.) 3. Name of the Karta (incase of Joint Hindu Family) 4, Whether belongs to: (a) Scheduled Caste/ Scheduled Tribe/ Backward Class/ Minority Community (0) Small Farmer/ Marginal Farmer/ Agriculture Labour 5. Deposit Accounts if any Name of the Bank Name of the Branch ‘Account No. 6. Particulars of land holdings (if lease-hold/ share-cropper, specify). Furnish copies of land records: Vilage | Survey Tile ‘Area of | Outof which | Source of ] encumbrance, if No/Block |~Owned ] Leased] Share- | land- | itrigated | irrigation any No. cropper | holding 7. Present annual income: @)__| Aaricuftural Income Rs, b)__| Other income Rs. Rs. TOTAL INCOME Bs. 8, Particulars of existing libilties as borrower, i any: Name ofthe institution Purpose of | Present | Ofwhich | Security | instalment Amt loan outstanding | over-due | offered | Repayable during the (Rs) (Rs) year (Rs.) {Our Bank 2, Other banks/ Goop. Gr Societies) LDBS (specify) Other Creditors (Govt dues)9. Liabilities as Guarantor: oan sanctioned to Wame of the ‘Amount of Loan] Balance outstanding ‘Status of Account Shri/Smt. Bank/Institution ason (Regular/ Overdue) 10. Particulars of Immovable and Movable assets/property owned: (2) IMMOVABLE Properties! assets: Particulars Number Present value | House / Building | Farm fand ‘¢_| Tractor Shed Farm Shed (b) MOVABLE properties assets: Particulars Number Present value Live Stock: Plough Cattle, Mich Cattle, Poultry birds Oil engine/ Electricity Motor” Pump sets Power Tiller Tractors Transport Vehicle Other implements House hold arteles 11.Securty (ies) proposed to be offered Particulars of Primary Security offered Particulars of Collateral Security (where applicable) 12, Guarantors offered, if any: Name of the Guarantor/s Worth _(Rs.) 13. Whether the applicant has availed benefit under Debt Waiver Scheme, 2008, if yes, give details: Declaration: © Wehereby declare that the particulars given above are true and correctto the best of my/our knowledge & belief © Wwe hereby authorize the bank to disclose all or any particulars or details or information relating to my/our loan accounts with the bank, to any other financial institution, Government or any agency, as may be considered necessary or desirable by the Bank © we hereby declare that Vwe have no borrowings/ bilities excepting those mentioned under item (8) and (9) above as onthe date of application © Ve authorize that it will be in order for the Bank to disqualify me/us from receiving any credit facilities from the bank in caseiitis proved that the declaration made above contain misrepresentation of facts © Vive undertake to repay & service the loans as per terms and conditions, © Wwe hereby undertake to abide by the terms and conditions thatthe Bank may stipulate in sanction ofthis loan & inform bankin he event of acquiring any other assets during the tenure of the advance. Applicant's Name Signature/s or Thumb Impressions Statement of particulars attested and person/s introduced for opening accountto avail loan for agriculture activity. Sarpanch ofthe PRI concerned Asstt Agriculture Officer concerned with seal with seal,