(HEAD OFFICE: MANDVI. BARODA) F. No.

135
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. Name in Full :
2. Age & Date of Birth :
3. Father’s/ Husband’s Name :
Mother’s Name :
4. Residential Address
i) Permanent Residence :

ii) Present Residence :

5. Telephone Numbers. Residence

: Office / Shop
Mobile
6. Occupation/ Line of Business : Service / Business / Professional
A If in service Name of employer
Address
:
Since When Working
Designation

B If in Business / Professional Name/s of the firm /

company
Address

:
Line/s of activities
Since when established
In which capacity he /
she is representing
7. Annual Income : Rs.
8. PAN (if an Income Tax Assesses) :
9. Details of Assets
9.1 Details of immovable properties (held in own name / joint name)
A. Nature of properties i) Plot of Land : ……………………..
ii) Agriculture Land : ……………………..
iii) House / Godowns : ……………………..
iv) Any Others : ……………………..
B. Location: Survey / House No
Area / Locality Village / Town:

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Signature.
 District PIN No.
C. Property in whose name? :
D. Cost (at the time of purchase) :
E. Present estimated market value of the property/ies :
F. Whether encumbered / un-encumbered / partially :
encumbered / un-encumbered / partially with whom.
Consideration and major terms and conditions.

9.2 Details of movable properties in my name:

A. LIC policies
Date of Annual Premium Premium Paid up
Policy No Sum assured Branch Name
issuance of Policy to what period

B. Shares/ Debentures etc.

Name of Total No. of Total Amount Rs. Whether fully Cur. Market
Certificate No
Company Shares held (Face Value) Paid (yes/No) Value Rs.

C. Term Deposits
FDR/RD/YSJ Name of Bank / Due Maturity
Date Favoring Amount
Y A/c No. Branch Date Value Rs.

D. Investment in Govt. Securities like Bonds/NSC etc.

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

9.3 Details like Reg. No. type and value of vehicle/s owned by me
Capital investment in business. Name of Firm / Company (As
9.4
on latest sheet date)
Full details of other investments if any (i.e. Jewellery,
9.5
Investment in other firm etc.)
9.6 Total of all assets (9.1 to 9.5) Rs.
10. Details of Loans in individual name/firms Name /Company’s Name:
A. Name/s of the Bank /other Institution and its :
branch

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Signature.
 B. Purpose and amount of Loan availed :
C. Security & repayment schedule/rate of interest :
D. Present balance outstanding :
E. Liabilities other than to bank and Financial :
Institution
11. Other Details: Details of personal guarantee given for :
any person/firm. If so furnish details (i.e. Name of Bank
/Institution, on whose behalf amount of guarantee present
status of a/c etc.)
12. A Particulars of Legal Heirs
S. No. Name Relationship D.O.B. Present Address

B Nomination particulars
Description of Asset (Bank
Bank / Account / Amount (at present / at
S. No. Dep., Co. Dep., Terminal
Organization certificate No. Maturity)
Benefits etc.)

In support of my above declaration, I enclose

1. Balance sheet, Profit and Loss Accounts, Trading Account, Capital Account audited/unaudited).
2. Copy of employment certificated 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.

13. I declare that.

I am/I am not (tick as applicable) a Director in ____/any Bank. There is no litigation against me or the firm/
Co. in which I am the proprietor/ a partner/ a Director.
The name of the firm /Co. or the name of the partners/Proprietor/Director of the firm/ Co. is not the caution
list of RBI/ECGC.
The proprietor/partners/directors of the firm/Co. is/are not the Directors in any Co-operative Bank.
I also declare that the above information is complete, true and correct.

Signature of the Applicant

Enclose:
Place:
Date:
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Signature.