Sidbi Fixed Deposit Application Form (Page 5 of 8) in pdf

Know Your Customer Form (KYC)

(For Individuals only)

(Use separate KYC form for each individual / joint holder)

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Please fill this form in BLOCK LETTERS (All information as applicable in Section A,B and C below is mandatory).

This information is sought under the Prevention of Money Laundering Act, 2002, the rules notified there under and SEBI guidelines on Anti Money Laundering.

A. Identity Details (Please see guidelines A1 to A5 overleaf)

1. Name of the Applicant (As in supporting document)

Title

Oth

Gender

Male

Female

Name

Father’s Name

Please paste most

2. Date of Birth

recent colour

photograph

3. Nationality

Indian

Others (Please specify)

(No staples please)

(Please tick any one)

30 mmx40 mm

4. Status

Resident Individual

Non Resident

Sign across the

(Please tick anyone)

photograph

5. Permanent Account Number (PAN)

(Please attach self attested photo copy of PAN Card)

B. Address Details (Please see guidelines B1 to B4)

Tel no

1. Address of

Mobile

Correspondence

E Mail

2. Permanent

Address

C. Proof of Address provided by Applicant (Please submit any one of the following certified documents and tick against the document attached)

Latest Telephone Bill

Latest Electricity Bill

Passport

Driving Licence

Latest Bank Account Statement

Latest Bank Passbook

Latest Demat Account Statement

Ration Card

Voter Identity Card

Registered lease/Sale Agreement of Residence

For NRIs – Any other document attested by local Authority

D. Proof of Identity provided by Applicant (Please submit any one of the following certified documents and tick against the document attached)

Passport

Photo Pan Card

Driving License

Voters’ ID card

Photo Ration Card

Photo Debit/Credit card issued by Bank

Any other identification with Photograph (subject to satisfaction of SIDBI)

E. Other Details (Please see guidelines C1 and C2 overleaf)

1. Gross Annual Income (Amount in Rupees) (Please tick anyone)

Upto `. 5,00,000

`.5,00,001 to `.25,00,000

`.25,00,001 to `.1,00,00,000

`.1,00,00,001 to `.5,00,00,000

Above `.5,00,00,000

2.a Occupation Details (please tick anyone)

Private Sector Service

Public Sector./ Government Service

Business

Professional

Agriculturist

Retired

Housewife

Student

Forex Dealer

Others

(Please specify)

2.b. If the following is additionally applicable to you (Please tick one or more as applicable)

Civil Servant

Bureaucrat

Current or former MP,MLA, MLC

Politician

Current or Former Head of State

DECLARATION

SIGNATURE OF THE APPLICANT

I hereby declare that the particulars given herein are true, correct and complete to the best of my knowledge and belief.

The documents submitted along with the application are genuine and I am not making this application for the purpose of

contravention of any Act, Rules, Regulations or any Statute or Legislation or any Notification/ Directions issued by any

governmental or statutory authority from time to time. I authorise SIDBI, its authorised agents and representatives to

disclose, share, remit in any form, mode or manner all /any of the information provided by me. I hereby agree to provide

Date : -

any additional information/documents that may be required in connection with this application.

Place : -

FOR OFFICE USE

Branch of SIDBI

Date of Receipt

Maker

Checker

Whether all information has been filled up by the applicant

YES

Copy of the documents submitted as identity proof and address proof have been verified with the originals as

produced by the applicant. Other KYC documents as required under the guidelines have been obtained and verified

YES

The names of the parties connected with the transaction have been checked in the latest updated list(s) of terrorist

individual / organizations circulated by KYC Cell and the name(s) of the depositor do not match with any name(s)

YES

mentioned in the said list(s).

Signature of Maker

Signature of Checker

Sidbi Fixed Deposit Application Form Page 5

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