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Rakesh PDF

The document contains a Know Your Client (KYC) application form for an individual named Rakesh Patel. The form collects details like identity, address, contact information, relationship and declaration. It is signed by Rakesh Patel using Aadhaar digital signature.

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patelrakesh44123
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0% found this document useful (0 votes)
97 views10 pages

Rakesh PDF

The document contains a Know Your Client (KYC) application form for an individual named Rakesh Patel. The form collects details like identity, address, contact information, relationship and declaration. It is signed by Rakesh Patel using Aadhaar digital signature.

Uploaded by

patelrakesh44123
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Know Your Client (KYC) Application Form - for Individuals

Please fill this form in English and BLOCK Letters


(Please tick the box on the left margin of the appropriate row where CHANGE/CORRECTION is required and provide the details in the corresponding window)

For office use only (To be filled by the financial institution)


Application Type* New Update KYC Number
Account Type* Normal Simplified (for low risk customers) Small

A. Identity details
Photograph
RAKESH PATEL
1. Name (Same as ID Proof) Please affix your
recent passport size
1a. Maiden Name (If any) photograph and
2. Father's/Spouse's Name NAGAJI PAYEL sign across it
2a. Mother's Name HEER PATEL
Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
F1
Date: 2024-03-16 16:07:34 IST

3a. Gender * Male Female Transgender 3b. Marital Status Single * Married Other 3c. DOB 2000-01-20
4a. Citizenship * Indian Other ___________________(ISO 3166 Country Code )
4b. Residential Status * Resident Individual Non Resident Indian Person of Indian Origin Foreign National
Tick if applicable Residence for tax purposes in jurisdiction(s) outside India
ISO 3166 Country Code of Jurisdiction of residence Place of birth_____________________________________
Tax Identification Number or Equivalent ISO3166 Country Code of Birth

5a. PAN FKOPP1789L


5b. Unique Identification Number (UID) / AADHAR, if any
6. Proof of Identity Submitted * Pan Card Other (Please Specify) ____________________________________
B. Address details
1. Contact Details
Telephone (Office) Mobile No 7073301605
Telephone (Residence) Email ID [email protected]
2. Residence/Correspondence Address Address Type: * Residential Business Unspecified
Address S/O NAGAJI PATEL WARD NO. 2 THANA
THANA THANA
City/Town THANA District DUNGARPUR Pin Code 314804
State/U.T Code RAJASTHAN Country/ISO Code INDIA
Specify the Proof of Address Submitted for Residence / Correspondence Address AADHAAR

C. DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and
I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be Signed by: Rakesh Patel
false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. eSigned using Aadhaar
(digio.in)
Date: F2
I hereby consent to receiving information from Central KYC Registry through SMS/email on the above registered Client Signature
2024-03-16 16:07:34 IST
number/email address.
Date :

FOR OFFICE USE ONLY


In Person Verification (IPV) Details:
Name of the Person who has done the IPV: ___________________________________________________
Designation: ____________________________________ Employee ID: __________________________
Name of the Organization: Zerodha Securities Pvt. Ltd.
Date of the IPV: Signature of the Person who has done the IPV Seal/Stamp of the Intermediary

Originals Verified and Self-Attested Document Copies Received

Date Signature of the Authorized Signatory

2 Sign wherever you see


3. Permanent Address
Address S/O NAGAJI PATEL WARD NO. 2 THANA
THANA THANA
City/Town THANA District DUNGARPUR Pin Code 314804
State/U.T Code RAJASTHAN Country/ISO Code INDIA

4. Address in the jurisdiction details where applicant is resident outside India for tax purpose (if applicable)
Address

City/Town District Pin Code


State/U.T Code Country/ISO Code

D. Details of related person (In case of additional related persons, please fill below details)
Addition of Related Person Deletion of Related Person
KYC Number of Related Person (if available)
Related Person Type Guardian of Minor Assignee Authorized Representative

Name
(If KYC number & name are provided, below details are optional)
Proof Of Identity Of Related Person
Identity Proof Submitted Number
Expiry Date :
Others (any document notified by the Central Govt.) Identification No
Simplified Measures Account-Document Type Code Identification No

3 Sign wherever you see


Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Date: 2024-03-16 16:07:34 IST
Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Date: 2024-03-16 16:07:34 IST
Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Date: 2024-03-16 16:07:34 IST
Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Date: 2024-03-16 16:07:34 IST
Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Date: 2024-03-16 16:07:34 IST
RAKESH PATEL
Joint Holder :- -
S/O NAGAJI PATEL WARD NO 03
MU PO THANA THANA
DUNGARPUR
DUNGARPUR Customer ID :898211803
RAJASTHAN IFSC Code :UTIB0001428
314804 MICR Code :314211002
Nominee Registered : Y
Registered Mobile No :XXXXXX1605
Registered Email ID:[email protected] PAN :FKOPP1789L
Scheme :SAVINGS-BASIC SAVINGS ACCOUNT

Statement of Account No :920010053381097 for the period (From : 17-09-2023 ToSigned


: 16-03-2024)
by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Date: 2024-03-16 16:07:34 IST
Tran Date Chq No Particulars Debit Credit Balance Init.
Br

OPENING BALANCE 31.01


IMPS/P2A/326621941747/RAKESHPA/FEDERA
23-09-2023 LB/null/9199999999999049000 21107.00 21138.01 1428
UPI/P2M/363286041707/Bharti Airtel
23-09-2023 Limited/Paymen/Axis Bank Ltd. 552.00 20586.01 1428
UPI/P2A/326926649373/Bank Account
26-09-2023 XXXXXXXX/Paymen/Baroda Rajasthan Ksh 20000.00 586.01 1428
920010053381097:Int.Pd:01-07-2023 to 30-09-
01-10-2023 2023 17.00 603.01 1428
ACH-CR-IRFC LTD-NACH-IR1509232228648-
05-10-2023 IR1509232228 1.40 604.41 2567
NEFT/CMS3627325984/NEXTBILLI/ICICI
07-10-2023 BAN/Groww Wi 18.18 622.59 248
UPI/P2M/366270366178/Bharti Airtel
23-10-2023 Limited/Paymen/Axis Bank Ltd. 157.00 465.59 1428
UPI/P2M/366219183441/Bharti Airtel
23-10-2023 Limited/Paymen/Axis Bank Ltd. 183.00 282.59 1428
UPI/P2M/366816325421/Bharti Airtel
29-10-2023 Limited/Paymen/Axis Bank Ltd. 101.00 181.59 1428
UPI/P2A/366830846439/PANNALAL PATEL
29-10-2023 /Paymen/State Bank Of India 157.00 24.59 1428
IMPS/P2A/330321120465/RAKESHPA/FEDERA
30-10-2023 LB/null/9199999999999049000 8010.00 8034.59 1428
UPI/P2A/330500157824/Bank Account
01-11-2023 XXXXXXXX/Paymen/Baroda Rajasthan Ksh 7000.00 1034.59 1428
UPI/P2A/368019839411/MOTILAL K/Axis
10-11-2023 Bank/Payment/ 10000.00 11034.59 1428
UPI/P2M/368876111479/Bharti Airtel
18-11-2023 Limited/Paymen/Axis Bank Ltd. 552.00 10482.59 1428
UPI/P2M/369242057241/Bharti Airtel
22-11-2023 Limited/Paymen/Axis Bank Ltd. 181.00 10301.59 1428
ACH-CR-IRFC INT DIV 23-24-NACH-
23-11-2023 IR1011230489714-IR 1.60 10303.19 2567
UPI/P2A/335454881489/Bank Account
20-12-2023 XXXXXXXX/Paymen/Baroda Rajasthan Ksh 9000.00 1303.19 1428
UPI/P2M/373173141031/Bharti Airtel
31-12-2023 Limited/Paymen/Axis Bank Ltd. 181.00 1122.19 1428
920010053381097:Int.Pd:01-10-2023 to 31-12-
01-01-2024 2023 39.00 1161.19 1428
UPI/P2M/436972252320/Bharti Airtel
03-01-2024 Limited/Paymen/Axis Bank Ltd. 19.00 1142.19 1428
UPI/P2M/437861293751/Bharti Airtel
12-01-2024 Limited/Paymen/Axis Bank Ltd. 552.00 590.19 1428
NEFT/SBI3240150008237/EC NEFT Parking
BGL a/c/STATE BANK OF
15-01-2024 INDIA//ATTN/NREAC/GLS//FOREIGN INWA 10000.00 10590.19 248
UPI/P2M/438432812995/Bharti Airtel
18-01-2024 Limited/Paymen/Axis Bank Ltd. 157.00 10433.19 1428
UPI/P2A/401888957932/NITESH PA/Baroda
18-01-2024 Ra/Payment/ 1.00 10434.19 1428
UPI/P2M/438868633908/Bharti Airtel
22-01-2024 Limited/Paymen/Axis Bank Ltd. 183.00 10251.19 1428
UPI/P2A/402355965723/Bank Account
23-01-2024 XXXXXXXX/Paymen/Baroda Rajasthan Ksh 2000.00 8251.19 1428
UPI/P2M/402424208698/NextbillionTechnology/
24-01-2024 Payvia/ICICI Bank 5000.00 3251.19 1428
UPI/P2M/439436676989/Bharti Airtel
28-01-2024 Limited/Paymen/Axis Bank Ltd. 181.00 3070.19 1428
UPI/P2M/403644499443/SONI ENTERPRISES
05-02-2024 /Rakesh/Indian Overseas Bank 1000.00 2070.19 1428
UPI/P2A/440374219285/MEHULKUMAR
06-02-2024 MUKESHBHAI/Paymen/Axis Bank Ltd. 4.00 2066.19 1428
UPI/P2M/404421091386/Zerodha Broking Ltd
13-02-2024 /985603/HDFC BANK LTD 2000.00 Signed by: Rakesh Patel 66.19 1428
eSigned using Aadhaar (digio.in)
NEFT/CMS3924633086/NEXTBILLION Date: 2024-03-16 16:07:34 IST
TECHNOLOGY PRIVA/ICICI BANK
14-02-2024 LIMITED/Groww Withdraw Req RAKESH PAT 983.54 1049.73 248
IMPS/P2A/404608440364/ZERODHAB/Remitter/
15-02-2024 IMPStran/9199869820207139000 1.00 1050.73 1428
UPI/P2M/441372962999/Bharti Airtel
16-02-2024 Limited/Paymen/Axis Bank Ltd. 181.00 869.73 1428
IMPS/P2A/406119561438/RAKESHPA/FEDERA
01-03-2024 LB/null/9199999999999049000 26791.00 27660.73 1428
UPI/P2M/442950418947/Bharti Airtel
03-03-2024 Limited/Paymen/Axis Bank Ltd. 181.00 27479.73 1428
UPI/P2M/406423848097/RANGOLI FASHION
04-03-2024 FACTO/Paymen/State Bank Of India 1200.00 26279.73 1428
ACH-CR-NHPC LIMITED-NACH-1809138-
05-03-2024 1809138 1.40 26281.13 2567
UPI/P2A/406778176907/Bank Account
07-03-2024 XXXXXXXX/Paymen/Baroda Rajasthan Ksh 10000.00 16281.13 1428
UPI/P2M/406791175372/groww
07-03-2024 /Payvia/Axis Bank Ltd. 5000.00 11281.13 1428
UPI/P2M/443365918139/PhonePe
07-03-2024 /Paymen/Axis Bank Ltd. 274.00 11007.13 1428
UPI/P2A/443455597839/ARVIND PA/Baroda
08-03-2024 Ra/UPI/ 1300.00 12307.13 1428
UPI/P2M/443523765665/Bharti Airtel
09-03-2024 Limited/Paymen/Axis Bank Ltd. 482.00 11825.13 1428
UPI/P2M/407067036874/Swag Cafe Dungarpur
10-03-2024 /Paymen/Axis Bank Ltd. 90.00 11735.13 1428
UPI/P2A/407164961314/JAGDISH PATEL
11-03-2024 /Paymen/Rajasthan Marudhara 27.00 11708.13 1428
NEFT/CMS4001978651/NEXTBILLION
TECHNOLOGY PRIVA/ICICI BANK
12-03-2024 LIMITED/Groww Withdraw Req RAKESH PAT 600.00 12308.13 248
UPI/P2A/407257935924/KHUSHI GA/Airtel
12-03-2024 Pa/UPI/ 100.00 12408.13 1428
UPI/P2A/407283618996/KALPESH PATEL
12-03-2024 /Paymen/India Post Payments 60.00 12348.13 1428
UPI/P2A/407242511681/KALPESH PATEL
12-03-2024 /Paymen/India Post Payments 15.00 12333.13 1428
UPI/P2A/443850756705/VIMAL PATEL SO
12-03-2024 TEJA P/Paymen/Union Bank of India 50.00 12283.13 1428
NEFT/CMS4004952020/NEXTBILLION
TECHNOLOGY PRIVA/ICICI BANK
13-03-2024 LIMITED/Groww Withdraw Req RAKESH PAT 700.00 12983.13 248
NEFT/YESB40757523548/ZERODHA
BROKING LTD-DSCNB A//YES
15-03-2024 BANK/YESB0000001 2000.00 14983.13 248
UPI/P2M/407590290668/groww
15-03-2024 /Payvia/Axis Bank Ltd. 2000.00 12983.13 1428
UPI/P2M/444135885387/Bharti Airtel
15-03-2024 Limited/Paymen/Axis Bank Ltd. 157.00 12826.13 1428
ATM-CASH-
15-03-2024 AXIS/BPRH142801/1576/150324/DUNGARPUR 2000.00 10826.13 1428

TRANSACTION TOTAL 70877.00 81672.12

CLOSING BALANCE 10826.13

Unless the constituent notifies the bank immediately of any discrepancy found by him/her in this statement of Account, it will be taken that
he/she has found the account correct.
The closing balance as shown/displayed includes not only the credit balance and / or overdraft limit, but also funds which are under clearing. It
excludes the amount marked as lien, if any. Hence the closing balance displayed may not be the effective available balance. For any further
clarifications, please contact the Branch.
We would like to reiterate that, as a policy, Axis Bank does not ask you to part with/disclose/revalidate of your iConnect passord,login id and
debit card number through emails OR phone call Further,we would like to reiterate that Axis Bank shall not be liable for any losses arising
from you sharing/disclosing of your login id, password and debit card number to anyone. Please co-operate by forwarding all such
suspicious/spam emails, if received by you, to [email protected]
With effect from 1st August 2016, the replacement charges for Debit card and ATM card applicable on Current accounts have been revised. To
know more about the applicable charges,please visit www.axisbank.com Signed by: Rakesh Patel
eSigned using Aadhaar (digio.in)
Deposit Insurance and Credit Guarantee Corporation (DICGC) insurance cover is applicable in all Banks' deposits, Date:such as savings,
2024-03-16 current,
16:07:34 IST
fixed, recurring etc* up to maximum amount of Rs 5 Lakh including principal & interest both* (* for exceptions and details please refer
www.dicgc.org.in )
In compliance with regulatory guidelines, the non-CTS cheque books attached to the accounts would be destroyed in banks core banking
System. Thus, Non CTS cheques will not be valid for CASH, Clearing and Transfer transactions
REGISTERED OFFICE - AXIS BANK LTD,TRISHUL,Opp. Samartheswar Temple, Near Law Garden, Ellisbridge, Ahmedabad .
380006.This is a system generated output and requires no signature.
BRANCH ADDRESS - AXIS BANK LTD, DUNGARPUR [RJ], OPPOSITE NEW BUS STAND, SAGWADA ROAD, , 314001,
DUNGARPUR, RAJASTHAN, INDIA, TEL:02964-230300/3130023 FAX:234600

Legends :
ICONN-Transaction trough Internet Banking
VMT-ICON-Visa Money Transfer through Internet Banking
AUTOSWEEP-Transfer to linked fixed deposit
REV SWEEP-Interest on Linked fixed Deposit
SWEEP TRF-Transfer from Linked Fixed Deposit / Account
VMT-Visa Money Transfer through ATM
CWDR-Cash Withdrawal through ATM
PUR-POS purchase
TIP/ SCG-Surcharge on usage of debit card at pumps/railway ticket purchase or hotel tips
RATE.DIFF-Difference in rates on usage of card internationally
CLG-Cheque Clearing Transaction
EDC-Credit transaction through EDC Machine
SETU -Seamless electronic fund transfer through AXIS Bank
Int.pd-Interest paid to customer
Int.Coll-Interest collected from the customer

++++ End of Statement ++++

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