SCRN : SC6 1 36 2 0 7 9

SARN : SA5 6 1 0 6 9 6 0
Branch Office

FORM DA-1: NOMINAT ION

No minatio n under Sectio n 4 5 ZA o f Banking Regulatio n Act, 19 4 9 and Rule 2(1) o f the Banking Co mpanies (No minatio n) Rules 19 85 in respect o f
Bank Depo sits,

I/ We (Name(s))

R/o
no minate the fo llo wing perso n to who m in the event o f my/o ur/ mino r's death, the amo unt o f depo sit in the acco unt may be returned by State Bank o f
India, Branch Office

DEPOSIT NOMINEE
Additio nal Details,if Relatio nship with
Nature o f Acco unt Acco unt No . Name Address Age Date o f birth
any depo sito r,if any

* As the no minee is mino r o n this date, I/we appo int Mr/Ms Age

Address to receive the amo unt o f the depo sit o n behalf o f the no minee in the event o f my/o ur/mino r's death
during the mino rity o f the no minee.

Place: KHONSA
Signat ure (s) / T hum b im pre ssio n(s) o f de po sit o rs
Date: 28/0 5/20 18

Where the depo sit is made in the name o f mino r, the no minatio n is to be signed by natural/legal guardian o f the mino r to act o n behalf o f the mino r.
*Strike o ut if no minee is no t a mino r

WIT NESSES
Nam e & Signat ure o f t he first wit ne sse s Nam e & Signat ure o f se co nd wit ne sse s
Name: ____________________________________________________ Name: ____________________________________________________
Signature: _________________________________________________ Signature: __________________________________________________
Address: _________________________________________________ Address: _________________________________________________
Place: ____________________________________________________ Place: ____________________________________________________
Date: ____________________________________________________ Date: ____________________________________________________
Telepho ne No : ______________________________________ Telepho ne No : __________________________________________

#Thumb impressio n(s) shall be attested by two witnesses; o therwise it shall be attested by o ne
witness...............................................................................................................................................................................................................

NOMINAT ION REGIST ERED

The abo ve mentio ned no minatio n is registered at serial no ____________________________________ in respect o f (Type o f Acco unt.)
_________________ Depo sit Acco unt No .___________________________________________.

Date_____________________. SS No ._______________ Fo r ________________

(Autho rised Official)

I want t he name of t he nominee t o be print ed on t he pass book.

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SCRN : SC6 1 36 2 0 7 9
SARN : SA5 6 1 0 6 9 6 0

Basic Savings Bank Deposit / Small Account Opening Form

Nam e & Signat ure o f t he first wit ne sse s
Name & Co de o f the Branch Affix
Passpo rt
Cust ID _________________________________________________
size Pho to
A/C No . _________________________________________________

1. Name in Full (Mr/Ms)

Mr. RAJIV KUMARSAH

2. Father/ Husband/Guardian Name

Mr. NAND KISHORSAH

3. Residential address:

C/o NAND KISHOR SAH

Ho use No . and name MS KHONSA HA ENTERPRISES Street No . and name BAZAAR ROAD

Landmark APMC Village/City KHONSA

District TIRAP Sub District/Tehsil KHONSA

State ARUNACHAL PRADESH Pinco de 79 2130

Census Co de _______________________
Telepho ne/Landline(With STD Co de) 0 70 0 50 4 36 4 7 Mo bile No . +9 1 70 0 50 4 36 4 7

4 . Sex: Male Female Date o f Birth: 30 /0 9 /20 0 1

M M D D Y Y YY

5. a) Occupatio n: Salaried Self-emplo yed Business Retired Student Others

b) Catego ry: General OBC SC ST

6 . KYC Do cuments Pro vided Yes No
7. No minatio n Required Yes No
8. Request fo r ATM Debit Card Yes No SMS Alert: Yes No

9 . Aadhar Number (if applicable)

Pleas e o p en a s mall d ep o s it ac c o unt und er lib erliz ed KYC no rms s p ec ified b y RBI. I und ertake to s ub mit the req uired /ad d itio nal KYC d o c uments as and when the
b alanc e o r the to tal annual trans ac tio n in my ac c o unt exc eed s the s tip ulated limit p res c rib ed b y RBI o r as and when req uired b y the Bank. In the event o f no n-
c o mp lianc e, the Bank is within its rig ht to s to p o p eratio ns in the ac c o unt
______________________________
Sig nature o f the Ap p lic ant

Please o pen a Small Acco unt / Basic Savings Depo sit Acco unt in the name o f Mr./Ms.
RAJIV KUMAR SAH
(first/so le applicant) and Mr./Ms. ______________________(seco nd Applicant)*. The Savings Bank rules and regulatio ns including tho se relating to
Small Acco unt / Basic Savings Depo sit Acco unt have been explained to me/us and I/we agree to abide by the same. An additio nal pho to graph o f
so le/each applicant is attached.
Fo r Basic Savings Bank Depo sit Acco unt
I do no t have any o ther Savings Bank Acco unt with SBI
I have a Savings Bank Acco unt with SBI and undertake to clo se it within 30 days o f o pening a Basic Savings Bank Depo sit Acco unt

Mode of Operat ion

Self Only Either o r Survivo r Fo rmer o r Survivo r Any o ne o r Survivo r Jo intly Other

Date: 28/0 5/20 18 ________________________________________ _______________________________________

Place: KHONSA Sig nature/Thumb Imp res s io n o f firs t/s o le Ap p lic ant Sig nature/Thumb Imp res s io n o f s ec o nd Ap p lic ant

Name & No . o f BC/BF. ________________________

Signature o f Business Co rrespo ndent/Facilitato r______________________
Name, SS No & Signature o f the verifying Branch o fficial_________________

* The Jo int Acco unt ho lder (i.e. seco nd applicant) shall fill up a supplementary Fo rm.

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SARN : SA5 6 1 0 6 9 6 0

ACCOUNT S OF INDIVIDUALS : LIST OF KYC DOCUMENT S

(o ne do cum e nt fro m e ach list )

1 . Individuals (ide nt it y do cum e nt s wit h sam e addre ss as t he o ne de clare d in Acco unt o pe ning fo rm )

Passpo rt
Vo ter's Identity Card
Driving Licence
Identity card issued by Po st o ffices
Identity card issued by Public autho rities who keep reco rd o f issue o f such identity cards.
Aadhaar Letter/Card
NREGA Card
Pensio n Payment o rders

2 . Individuals (whe re ide nt it y do cum e nt s are wit h diffe re nt addre ss) - One do cument each fro m List 1 and List 2 which sho uld be mutually
exclusive
Pro o f o f ide nt it y (List 1 ) Pro o f o f addre ss (List 2 )

Passpo rt Telepho ne bill (no t mo re than 3 mo nths o ld)

Vo ter's Identity Card Bank acco unt Statement (No t mo re than 3 mo nths o ld)
Driving Licence Letter fro m any reco gnized public autho rity
Aadhaar Letter /Card Electricity bill (no t mo re than 6 mo nths o ld)
Identity card issued by Public autho rities Co pies o f Registered Leave & License agreement/ Sale
Pho to identity cards issued to bo nafide students by a university Deed/Lease Agreement
appro ved by UGC/AICTE Letter issued to students by Ho stel warden o f the University/ I
Go vt./Defence ID Card Institute, where the student resides, duly co untersigned by the
Registrar/ Principal/Dean o f Student Welfare
ID Cards issued by reputed emplo yers
In case o f students/ clo se relatives, identity and address o f the
NREGA Card
relative who m they are staying alo ng with the declaratio n fro m such
Pensio n Payment o rders
perso n.
Identity card issued by Po st o ffices Ratio n card
PAN Card Letter fro m reputed emplo yer
Inco me Tax/ Wealth Tax Asses-ment o rders
Credit Card Statement (no t mo re than 3 mo nths o ld)

T o be filled by those who do not have PAN

FORM NO. 6 0 FORM NO. 6 1
[ See seco n d p ro visio n ru le 114 B ] [ See p ro visio n t o clau se ( a) o f ru le 114 C ( 1) ]
Fo rm o f d eclarat io n t o b e f iled b y a p erso n wh o d o es n o t h ave a Fo rm o f d eclarat io n t o b e f iled b y a p erso n wh o h as ag ricu lt u ral
p erman en t acco u n t n u mb er an d wh o en t ers in t o an y t ran sact io n in co me an d is n o t in receip t o f an y o t h er in co me ch arg eab le t o
sp ecif ied in ru le 114 B in co me- t ax in resp ect o f t ran sact io n s sp ecif ied ru le 114 B
1. Full name and address of the declarant Mr.RAJIV KUMAR SAH 1. Full name and address of the declarant _____________________________
_______________________________________________________________
KHONSA 01 Mr. 02 Mrs. 03
Ms. 99 Others. 2. Particulars of transaction (a) Opening of accounts
2. Particulars of transaction (b) Issuance of ATM cum D ebit Card

(a) Opening of accounts SAVING 3. D etails of the documents being produced in support
of Address in column (1): Yes No
(b) Issuance of ATM cum D ebit Card YES
I hereby declare that my source of income is from agriculture and
3. Amount of the transaction 1000000 I am not required to pay income-tax on any other income, if any.

4. Are you assessed to tax? Yes No

5. If yes,(i) D etails of Ward/Circle/Range where the last return of income was
filed
(ii) Reasons for not having permanent account Number:

6. D etails of the document being produced in support of address In column(1)

VERIFICAT IO N

I, RAJIV KUMAR SAH , do hereby declare that what is stated abo ve is true to the best o f my kno wledge and
belief. Verified to day, the 28 day o f May 20 18
Date: 28/0 5/20 18 Place: KHONSA Signature o f the declarant

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SCRN : SC6 1 36 2 0 7 9
SARN : SA5 6 1 0 6 9 6 0

Basic Savings Bank Deposit Account Opening Form - ADDIT IONAL INFORMAT ION

1. Mode of Operat ion:

Self Only Either o r Survivo r Fo rmer o r Survivo r Any o ne o r Survivo r Jo intly Other

2. PAN /GIR NO./FORM 6 0 /6 1

3. Inco me Per annum 10 0 Assets (appro ximate value): Rs. ________________

4 . Educatio nal Qualificatio n No n- Graduate Graduate Po st Graduate Others

5. Email ID RAJIVSAH24 0 @GMAIL.COM

6 . KYC Do cuments Pro vided Identificatio n Pro o f:

Address Pro o f

7. Request for add on:

S.No Pro duct

1 e-Statement o f Acco unt Yes No
2 Cheque Bo o k Yes No
3 Mo bile Banking Yes No
4 Internet Banking Yes No
5 Credit Card Yes No
6 Request fo r ATM Debit Yes No
7 SMS Alert Yes No
8 Others Yes No Specify

8. Addit ional Informat ion for Cross Selling

I wo uld like to also avail:

S.No Pro duct

1 Ho using Lo an Yes No
2 Vehicle Lo an Yes No
3 Mutual Fund Yes No
4 Life/General Insurance Yes No
5 Pensio n Yes No
6 Others Yes No Specify

I/we understand that a bo o klet o n the Banking Co des & Standards Bo ard o f India Co de(BCSBI) po sted o n yo ur website shall be pro vided to me o n
demand.

T erms & Condit ions:

I/we co nfirm having received, read and understo o d (a) the acco unts rules and hereby agree to be bo und by the terms & co nditio ns o utlined in these
rules which go verns the acco unt(s) which I/we am/are o pening/will o pen and (b) amendments to the rules made fro m time to time and tho se relating to
vario us services availed by me/us when displayed by the Bank o n its no tice bo ard o r o n its website and tho se relating to vario us services o ffered by the
Bank including but no t limited to debit card, credit card, internet banking mo bile banking and o ther facilities listed in this fo rm. The usage o f these
facilities is go verned by the terms and co nditio ns stipulated by the Bank fro m time to time.

Date: 28/0 5/20 18

Place:KHONSA Signature/Thumb Impressio n o f first/so le Applicant Signature/Thumb Impressio n o f seco nd

Applicant

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