eKYC ACCOUNT OPENING FORM (BC POINT-System Generated) Page 1 of 2

SB - FINANCIAL INCLUSION
eKYC ACCOUNT OPENING FORM (BC POINT-System Generated)
Ref.No. 115105021378 Date of account opening : 01-07-2021

Name of the Branch RAJGARH (BIORA) SOLID 4529

Village/Town/City RAJGARH MP Sub District/Block Name/District RAJGARH
District RAJGARH State MADHYA PRADESH
SSA Code/Ward No.
Village Code/Town Code (as per Name of Village/Town (as per census
479275 PIPLODI
census 2011) 2011)

Applicant Details:

A/C Number 45298100017276 CUST ID XXXXX9715

A/C Type SB-FINANCIAL INCLUSION Scheme Code SB150
Full Name MR Parte Singh
Marital Status UNMARRIED Gender Male
Name of Father MR RAM PRSAD
Name of Mother RAMKANYA BAI
Name of Spouse
Permanent Address
GRAM AVANPUR POST PIPLODI TEHSEEL RAJGARH PIPLODI RAJGARH MADHYA PRADESH 465661
(As per Aadhaar)
Declaration for Local Address when Address as per Aadhaar is different from current address: Declare that I submitted below Aadhaar as proof of Identity & Address for the purpose of account opening.
However, I hereby declare that my current address is as under
Current Address
(Self-declared)
Residing Since
Pin Code 465661
Telephone No XXXXXX1356 Date Of Birth 14-06-2008
Mobile No XXXXXX1356
Aadhaar XXXX XXXX 0832 Pan Number NA
Nationality INDIAN Religion HINDU
Category
Disability
Education
Occupation/
STUDENT
Profession
Monthly Income Rs.0 Net Worth Rs.0
No. of Dependents
Details Of Assets:
Owning House Owning Farm
No. of Animals owned Any other
Existing Bank A/C of family
members/ household
Kisan Credit Card
 I request you to issue me a RuPay Card (PMJDY) in my name given above
I request you to enroll me under Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY)
I request you to enroll me under Pradhan Mantri Suraksha Bima Yojana (PMSBY)
Declaration cum undertaking

• I hereby apply for opening of a BSBD Bank Account. I declare that I do not have any other Bank account in Bank of Baroda and another BSBD account with any other bank. The terms and
conditions applicable have been read over and explained to me and have understood the same. I shall abide by all the terms and conditions as may be in force from time to time.
• I hereby declare that I have submitted the Aadhaar Card issued by UIDAI voluntarily for identification and address proof towards the compliance of KYC norms under the PMLA, 2002. I hereby
consent that the Bank may verify the same with UIDAI and authorise the UIDAI expressly to release the identity and address through biometric authentication.
• I hereby consent that my Aadhaar number shall be seeded in my Bank Account for receipt of DBT benefits.
• I declare that my Aadhaar is not seeded with any other Bank for receiving DBT benefits (I understand that NPCI will reject mapping request, if my Aadhaar number is already mapped to any other
Bank). OR my Aadhaar is currently seeded with ___________________________________ (name of bank) and request you to change DBT mapping at NPCI from my account with that bank to my
account with Bank of Baroda. (I understand that my NPCI mapping for receiving DBT benefit will not be changed from previous bank in the event of my PMJDY overdraft continuing to be
outstanding in that bank)
• I understand that I am eligible for an Overdraft (under PMJDY scheme) after satisfactory operation of my account after 6 months of opening my account with a maximum limit of Rs. 10,000/-
(Rupees ten thousand only) and fulfilling other terms and conditions of the scheme, for meeting my emergency/ family needs subject to the condition that only one member from the household will be
eligible for overdraft facility. I declare that I have not availed any Overdraft or Credit facility from any other bank. I shall abide by the terms and conditions stipulated by the Bank in this regard.
• I declare that at the time of account opening, I have requested for issue of RuPay card (PMJDY) and I have submitted my request for enrolment under the following micro insurance schemes

https://bob.ngm-fi.com/customeradditionaldetails.do?method=ACCOUNTOPENFORM 01-07-2021
eKYC ACCOUNT OPENING FORM (BC POINT-System Generated) Page 2 of 2

PMJJBY (Pradhan Mantri Jeevan Jyoti Bima Yojana

PMSBY (Pradhan Mantri Suraksha Bima Yojana
• FATCA Declaration: I declare that I am a citizen of India by birth and resident in India as well as resident for tax purposes in India and not of any other country other than India
• I declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform the Bank of any charges therein, immediately. In case any of the above
information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.
• I agree that my personal KYC details may be shared with Central KYC registry or any other competent authority. I hereby give consent to receive information from the Bank / Central KYC Registry /
GOI / RBI or any other authority through SMS / e-mail on my registered mobile number / e-mail address. I also agree that the non-receipt of any such SMS / e-mail shall not make the Bank liable for
any loss or damage whatsoever in nature.

Form No 60 (If PAN is not provided)

 I do not have PAN and details of my income for the year is given below;

a) Agricultural Income Rs. 0

b) Other than agricultural income Rs. 0

I do hereby declare that what is stated above is true to the best of my knowledge and belief. I further declare that I do not have a Permanent Account Number and my estimated total income (including
income of spouse, minor child etc., as per section 64 of Income Tax Act, 1961) computed in accordance with the provisions of Income Tax Act, 1961 for the financial year will be less than the maximum
amount not chargeable to tax.
Place: ___________________________
Date: 01-07-2021
(Signature / LTI of applicant)
Nomination From-DA1:
I do not want to nominate anybody in this account
 I want to nominate the following person to whom in the event of my death the amount of this deposit particulars of which given above may be returned by Bank of Baroda
 I want the name of the nominee to be printed on the passbook

Person authorized to receive the amount in case of minor death

Name of Nominee Relationship Age Date of Birth,in case of minor
during the minority of the nominee
RAMPRASAD FATHER 41 01-01-1980

Obtain latest
photograph not
older than six month

Place:PIPLODI

Date:01-07-2021 (Signature / LTI of applicant)

Witnessed by -
Name of BC agent:KAMAL SINGH KOID:11510502

Address of BC agent:GRAM GURADKHED POST PIPLODI RAJGARH MP 465661 MP RAJRA 465661

Signature of BC agent
Enclosed: Self attested copy of Aadhaar.
FOR OFFICE USE AT BC / CSP LEVEL
Name of BC agent: KAMAL SINGH KOID 11510502
Date of submission to link
Date of enrolment:
branch:

Date
Signature of BC agent:

For office use at link Branch

Particulars of a/c opened
Received on:
tallied with a/c opening form:
Account No: 45298100017276 CUSTID: XXXXX9715
A/c unfreeze in FREEREC Photo & Signature uploaded
on: on:
Date
Signature of BM at Link Branch

https://bob.ngm-fi.com/customeradditionaldetails.do?method=ACCOUNTOPENFORM 01-07-2021