SB - FINANCIAL INCLUSION

ACCOUNT OPENING FORM (BC POINT-System Generated)

Ref.No. SB327714049826 Date 04-OCT-2023

Name of the Branch KANGRA SOLID 5416

Village/Town/City KANGRA Sub District/Block Name/District KANGRA
District KANGRA State HIMACHAL PRADESH
SSA Code/Ward No.
Village Code/Town Code [as per census Name of Village/Town [as per census
2011] 2011]

Applicant Details:

A/C Number 54168100002314 CUST ID XXXXX7135

A/C Type SB-FINANCIAL INCLUSION Scheme Code SB150
Full Name MR.Vijay Kumar
Marital Status UNMARRIED Gender MALE
Name of Father MR AKAR SINGH
Name of Mother
Name of Spouse
Permanent Address
Village Tiulla Teh Bharmour Auhra 22 Chamba Himachal Pradesh KANGRA HIMACHAL PRADESH IN 176324
(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 Village Tiulla Teh Bharmour Auhra 22 Chamba Himachal
Residing Since 04-10-2023
(self-declared) Pradesh KANGRA HIMACHAL PRADESH IN 176324
Pin Code 176324
Telephone No. XXXXXX7051 Date of Birth 19-02-1996
Mobile No. XXXXXX7051
Aadhaar (masked) XXXXXXXXXX7808 PAN No. XXXXXXX25K
Nationality IN Religion HINDU
Category ST
Disability No
Education
Occupation/
OTHERS
Profession
Annual Turnover Rs.3000.00 Gross Income Rs.
No. of Dependents

Owning House Y No. of Animals owned

Detail of Assets:
Owning Farm Any other
Existing Bank A/C of family
NO If yes, No. of A/cs
members/ household
Kisan Credit Card N

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 BANK OF BARODA 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
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)

a) Agricultural Income NA
b) Other than agricultural income NA

I do hereby declare that what is stated above is true to the best of my cknowledge 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: KANGRA M CL
Date: 04-OCT-2023
(Signature / LTI of applicant)
Nomination From-DA1: (Under Section 45ZA of Banking Regulation Act, 1949 and rules 1985 in respect of Bank Deposits)
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

Name of Nominee Relationship Address Pincode Age Gender Date of Birth in case of minor
AURA TIULLA
TEHSIL
BHARMOUR
AKAR SINGH FATHER 176324 53 M 15-11-1969
KANGRA
HIMACHAL
PRADESH INDIA
Person authorised to receive the amount on behalf of the nominee in the event of my /minor(s) death.

Name of Guardian Relationship Address Pincode Age Gender

Obtain latest
photograph not
older than six
month

Place:KANGRA M CL
Date: 04-OCT-2023 (Signature/LTI of Applicant)
Witnessed by - Name of BC agent:REENA KUMARI KOID:11241049
Address of BC agent:CHAMIYARA DHARAMSHALA, HARI KHAS CHARR, KANGRA, HIMACHAL PRADESH
Signature of BC agent
Enclosed: (1) Self attested copy of Aadhaar; (2) Self attested copy of PAN (if PAN is submitted)
For office use At BC/CSP level

Name of Primary BC agent: REENA KUMARI KOID 11241049

Date of submission to link

Date of enrolment: 04-OCT-2023
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: 54168100002314 CUSTID: XXXXX7135
A/c unfreeze in FREEREC Photo & Signature uploaded
on: on:

Date: Signature of BM at Link Branch