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SB - FINANCIAL INCLUSION
ACCOUNT OPENING FORM (BC POINT-System Generated)
Ref.No. SB335112977633 Date 17-DEC-2023

Name of the Branch SATNA SOLID 8783

Sub District/Block
Village/Town/City BHOPAL SATNA
Name/District
District SATNA State MADHYA PRADESH
SSA Code/Ward No.
Village Code/Town Code Name of Village/Town
458024 SATNA
[as per census 2011] [as per census 2011]

Applicant Details:

A/C Number 87838100010520 CUST ID XXXXX6462

A/C Type SB-FINANCIAL INCLUSION Scheme Code SB150
Full Name MR.Babli Saket
Marital Status MARRIED Gender MALE
Name of Father MR GOPAL SAKET
Name of Mother MRS SHANTI SEN
Name of Spouse
Permanent Address 00 hanuman nagar nai basti ward no.15 tahseel Raghurajnagar Raghurajnagar Satna Madhya Prad SATNA
(As per Aadhaar) MADHYA PRADESH IN 485005
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
00 hanuman nagar nai basti ward
no.15 tahseel Raghurajnagar
Current Address
Raghurajnagar Satna Madhya Prad Residing Since 17-12-2023
(self-declared)
SATNA MADHYA PRADESH IN
485005
Pin Code 485005
Telephone No. XXXXXX4608 Date of Birth 01-01-1989
Mobile No. XXXXXX4608
Aadhaar (masked) XXXXXXXXXX0352 PAN No. NA
Nationality IN Religion HINDU
Category OBC
Disability No
Education BELOW SSC
Occupation/ LABOURER

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Profession
Annual Turnover Rs.50000.00 Gross Income Rs.40000
No. of Dependents
Owning House N No. of Animals owned 0
Detail of Assets:
Owning Farm N Any other 0

Existing Bank A/C of

family members/ NO If yes, No. of A/cs
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)

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

a) Agricultural Income Rs. 5000

b) Other than agricultural income Rs. 5000

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

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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: AMARPATANNP
Date: 17-DEC-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
WARDNO17
HANUMANNAGAR
RESHMA SAKET WIFE SATNA SATNA 485001 30 F 31-08-1993
MADHYA
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:AMARPATANNP
Date: 17-DEC-2023 (Signature/LTI of Applicant)
Witnessed by - Name of BC agent:AJAY DWIVEDI KOID:17005246
Address of BC agent:Amarpatan Satna MP
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
AJAY DWIVEDI KOID 17005246
BC agent:

Date of
Date of
17-DEC-2023 submission to
enrolment:
link branch:

Date: Signature of BC agent

For office use at link Branch

Particulars of a/c
opened tallied
Received on:
with a/c opening
form:
Account No: 87838100010520 CUSTID: XXXXX6462
A/c unfreeze in Photo & Signature
FREEREC on: uploaded on:

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Date: Signature of BM at Link Branch

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