STATE BANK OF INDIA

FINANCIAL INCLUSION ACCOUNT OPENING FORM

Reference Number: Date:

Name of the Branch

Village/Town
Sub District/Block
Ward No.:
Name
District State:
Name of
Village Code /Town
Village/Town
Code
[as per census
[as per census 2011]
2011]
EKYC
CKYC Number
Certificate
Number
CIF Number Account Number

Name
Date Of Birth
Gender
Marital Status
Father Name
Spouse Name (If
married)
Mother's Name
Nationality IN-Indian Others (ISO 3166 -Country Code)
Number of
Citizenship Indian
Dependents
Place Of Birth Maiden Name
Designation/
Religion
Profession
Caste
S-Service Private Public Government Sector
Self- Retired House wife
Occupation Type O-Others
Professional Employed Student
B-Business
PAN / Form 60 Mandatory. If
customer provides
PAN, PAN Details to be Name Fetched
captured. If customer From NSDL
provides Form 60,
capture
below mentioned data
Date of FORM60 Aadhaar
Transaction
submission by date Number if
customer given
Income from Income from
Annual Income
Agriculture other
sources
PAN Applied but
not yet
generated flag
Applied
Date of
Acknowledgement no
PAN
for PAN Applied
Applied
Residential Status India
ISO 3166 Country
code of country of IN - Indian
Tax residence
Current Address:

PIN Code:-
Address
Communication

Address:

Mobile No.
Identification
Details and (Proof
of Identification)
Proof of
Address Details
I request you to
issue me a Repay
Card.
CKYC Expiry Date

I, the holder of Aadhaar number , hereby submit my Aadhaar number and

voluntarily give my consent to State Bank of India to: - 1. Seed my Aadhaar / UID number issued by UIDAI,
Government of India (GOI) in my name with this Account.
Map it at NPCI to enable me to receive Direct Benefit Transfer (DBT) from GOI in this Account. I understand
that if more than one benefit transfer is due to me, I will receive all Benefit transfers in this Account.
Use my Aadhaar details to authenticate me from UIDAI.
I voluntary consent to my fingerprints being taken and stored by the State Bank of India for the purpose of
availing banking services including operation of account(s), for delivery of services and any other facility
relating to banking operations ('Purposes').
I have been given to understand that my information submitted to the Bank herewith shall not be used for
any purpose other than mentioned above, or as per requirements of law.
Use my mobile number mentioned above for sending SMS alerts to me. I also give my consent for
sharing/receiving information with/from CKYC registry through SMS on my above registered mobile number
I also understand that I am eligible for an Overdraft after satisfactory operation of my account after 6
months of opening my account with a Limit up to Rs.10,000/- or any other permissible limit in force from
time to time for which I may be eligible depending upon the eligibility criteria of SBOD scheme, for meeting
my emergency/ family needs subject to the condition that only one member from the household will be
eligible for overdraft facility. Further I hereby declare that I have not availed any overdraft or credit facility
from any other bank. I hereby undertake to abide by the terms and conditions that the Bank may stipulate in
sanction of SBOD. I hereby agree that in the event of breach of undertaking or terms and conditions subject
to which overdraft facility is sanctioned and /or any of the undertakings or information, the Bank at its sole
discretion may discontinue the OD facility. I hereby undertake and agree to repay the outstanding together
with interest, cost, charges, etc in the event of termination or discontinuation of the facility.
8. I hereby certify that I have declared my status as per the rules applicable under section 285BA of the
Income Tax Act, 1961 as notified by Central Board of Direct Taxes (CBDT) vide Notification No. S.O. 2155
(E) dated 7 August 2015 and RBI Circular Ref No. DBR.AML.BC. No.36/ 14.01.001/2015-16 dated 28 August
2015 in the matter including any subsequent modification/amendment thereof.
9. I understand, acknowledge and authorize that as per the provisions of Income Tax Act, Rules made
thereunder and the guidelines issued by the Government/RBI in the matter, depending upon the residential
status and/or other criteria stipulated therein, the Bank may have to report the details in respect of my
account(s) as per the prescribed format to the Central Board of Direct Taxes (CBDT) or other Government
Agencies to comply with the obligations as per the Inter- Governmental Agreements (IGA) in respect of
Foreign Accounts Tax Compliance Act (FATCA) and Common Reporting Standards (CRS) and / or any other
similar arrangements.
10. I undertake the responsibility to declare and disclose immediately and in no case beyond 30 days from
the date of change, any changes that may take place in the information provided herein/or otherwise, as
well as in the documentary evidence provided by me or if any certification becomes incorrect or undergoes
a change. I further undertake to provide fresh and valid self-certification along with documentary evidence
as and when so required; nevertheless, all declaration and undertaking given herein will also be applicable
to all such modified/amended documents/information provided by me unless revised self-certification as
above is provided to the Bank.
11. I also agree that my failure to disclose any material fact/information known to me now or in future or my
failure to remedy any deficiency in documents/information/other details within the stipulated period, may
invalidate me from transacting in the account and the Bank would be within its right to put restrictions in
the operations of my account or to close it or to report to any regulator and/or any authority designated by
the Government of India (GOI)/RBI for the said purpose or take any other action as may be deemed
appropriate by the Bank under the guidelines issued by CBDT/RBI/GOI from time to time.
12. I also agree to furnish and intimate to the Bank any other particulars that are called upon me to provide
on account of any change in law either in India or abroad in the above matter or otherwise.
13. I shall indemnify the Bank from any loss/damage that may be caused to the Bank on account of any
defect/mistake in the details provided herein or on account of providing incorrect or incomplete information
by me.

Nomination:

I want to nominate as under

Mobile No Person authorized in case to receive the amount
Name of Date of Birth in
Relationship Age of Nominee of deposit on behalf of the nominee in the event
Nominee case of minor
e of m y/minor(s) death.
 OR

I do not want to nominate any person in this account.

Date:
Signature / Thumb Impression of Applicant
Place:

Witness-1 Witness-2

Form No. 60(See second proviso to rule 114B)

by an individual or a person (not being a company or firm) who does not have a permanent account number and who enters into any tr

Verification

I, do hereby declare that what is stated above is true to the best of my knowledge
and b elief. I further declare that I do not have a Permanent Account Number and my / our estimated total income (includin

Verified today, the .

PLACE:
Signature / Thumb Impression of Applicant

Witness-1 Witness-2

Name: Name:
Signature: Signature:
Address: Address:

SIGNATURE:

KO NAME: - KO CODE: -
FOR OFFICE USE AT BC/CSP LEVEL

NAME: - CSP CODE: -

FOR OFFICE USE AT LINK BRANCH
Particulars of a/c opened tallied with a/c opening
form

Account No.

Card No. Signature of BM at Link branch

SS NO :-

Date :-