Date: __/__/___ Account No.

⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
CIF ID ⬚⬚⬚⬚⬚⬚⬚⬚ Type of Account: Savings ⬚ Current ⬚ FD ⬚ RD ⬚

Account Details

Section A
I/We request you to close my/our Current/ Saving Account/Fixed/Recurring Deposit Name
⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚

1st Holder Name ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚

2nd Holder Name ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
3rd Holder Name ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
If there are more than 3 holders then please fill up the additional form

Please tick the appropriate option(s):

S. N. Product (✓) S. Product (✓) S. Product (✓) S.N. Product (✓)
N. N.
1 CASA 3 Locker 5 Other ECS/SI 7 Loan
2 FD/RD 4 SI for Kids 6 ACH Debit Clearing 8 Gold Loan

⬚ I/We am/are aware that my/our savings/current account will not get closed, in case of any of the above product(s) is/are linked
to my/our savings/current account and I have not submitted additional request for delinking or closing these products. Please also
note that any other ECS/SI of other company linked to this account will get closed/deleted consequent to the closure. I am aware
that the time lines will be applicable only if the CASA account does not have any linkages.

⬚ I/We confirm that all unused cheques issued to me/us have been enclosed/destroyed by me/us (Nos. from _______________ to
____________________). I/We also authorize the bank to destroy all the unutilised cheques, if any, in the system.

⬚ I/We are enclosing/ destroying the ATM/Debit Card(s) issued to me/us.

No. 1 ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ No. 2 ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚

Section B
I/We request you to partial withdrawal my Fixed Deposit with amount ₹ _____________________
1st Holder Name ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
2nd Holder Name ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
3rd Holder Name ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
If there are more than 3 holders then please fill up the additional form

Pay the proceeds by:

⬚ Cash* (except FD/RD) / ⬚ Demand Draft / ⬚ Credit to USFB Bank Account / ⬚ Credit to Other Bank Account

Credit Account No ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ ⬚ I/we am/are attaching a cancelled

Beneficiary Bank name cheque/latest bank statement/copy of
passbook issued by the beneficiary bank for
Beneficiary Branch name verifying the accuracy of the given details
Beneficiary IFSC Code * As per the current income tax rules, if the
account balance at the time of account
Beneficiary Branch Address
closure exceeds Rs. 20000/- the payment will
not be made by Cash

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Reason for closure of account

Sr. select Sr. select

Reason Reason
No. (✓) No. (✓)
Unhappy with the services provided by
Corporate Salary Account-Employer
1 the Bank (service quality/staff 9
changed
behaviour/turnaround time)
Transferred to a non-USFB Bank branch
2 Product deficiency 10
account
Monthly/Quarterly/Half yearly non Consolidating Bank Account within USFB
3 11
maintenance charges on higher side Bank
Monthly/Quarterly/Half yearly average Consolidating Bank Account- other
4 12
balance on higher side Banks
Shifted to other location where there is Account wrongly opened (incorrect
5 13
no USFB Bank branch name, branch or product type etc.)
Recurring/Fixed Deposit – Premature Legal/Regulatory/KYC/AML (Income-
6 14
closure/Matured Tax/KYC/AML/Court order etc.)
PGKN –Initial pay-in returned/documents
7 Customer Deceased 15
insufficient
Specific product facility no longer
8 16 As Business shut down/business closed
required (overdraft/loan etc.)

De-Linking/Re-Linking

I/We request you to delink following products from my A/C no. ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
And relink the same to my alternate A/C no. ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚

(Please (✓) the product for Delinking request)

(✓) Description A/C no. to be Delinked Term & Condition
FD for Interest ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
/Maturity Payment
RD for Maturity ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
Locker for SI debit ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ Alternate Account no is mandatory
Minor A/C for SI debit ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ for delinking
Loan Type ________________________________ As per requirement I am submitting
Loan Account no 1 ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ 3 security cheque leaves duly
signed from my alternate account
Loan Type ________________________________ number & SI Debit Authorization
Loan Account no 2 ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ Form for loans
Loan Type ________________________________
Loan Account no 3 ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚

Please relink above mentioned product with account as mentioned below:

⬚ Credit to USFB Bank Account / ⬚ Credit to Other Bank Account

Credit Account No ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ ⬚ I/we am/are attaching a cancelled

Beneficiary Bank name cheque/ latest bank statement/ copy of
Beneficiary Branch name passbook issued by the beneficiary
bank for verifying the accuracy of the
Beneficiary IFSC Code given details
Beneficiary Branch Address

Withdraw of ACH Debit Clearing Mandate

I/We hereby request you to withdraw ACH Debit Clearing Mandate as per below details:
CIF ⬚⬚⬚⬚⬚⬚
Account No ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚
Name of the Account Holders
Name of the beneficiary(Scheme/Purpose)
Amount of Instalment / Amount of bill with upper Limit
ACH Debit Start date

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ACH Debit End date (Original Date given in the ACH
Debit Mandate)
Effective Date(To be filled by customer)
Note- Stop payment/withdrawal instruction will be applicable after 3 working days or next cycle whichever is later.

Request to withdrawal instruction of ACH debit clearing mandate:

I/We declare that the information provided is complete and true to my knowledge. I also confirm that I will provide
this instruction to Beneficiary Institution/ Mutual Fund House for updation in their records
Customer Signature (As per Mode of Operation)
First Holder Second Holder Third Holder

Terms & Conditions (for Standing Instruction mandate)

1. I/We undertake to keep sufficient funds in the funding account on the date of execution of the standing instruction. The failure
on part of me/us to maintain sufficient balance in the said Account(s) shall not any way impair the right of the Bank to debit the
service charges.
2. I/We hereby authorize the Bank to debit my account & execute the standing instruction as per the instruction provided above.
3. I/We authorize the Bank to debit my account debit all types of Bank charges/commission/fees (service charges) payable by me/us.
4. I/We understand that a maximum of 3 attempts shall be made to execute the standing instruction; after which no further action
shall be taken.
5. The Bank shall not be obliged to provide the overdraft facility on the said Account but for towards the debiting of service charges
payable by me/us. I/We specifically agree and confirm that any matter or issue arising hereunder shall be governed by and
construed exclusively in accordance with the Indian laws and shall be subject to the jurisdiction of the courts of Varanasi in India.

The Bank may contact you for further discussion at your registered mobile number post which the closure process will be initiated.
In case you would like to be contacted at an alternate number, please provide the details:

Mobile No. ______________________________ Landline No. (with STD code): _______________________________

Names & Signatures of all applicants: in case of more signatories please use an additional form

Name

Signature First Holder Second Holder Third Holder

Bank Use Only

Date of Account Opening: __/__/__
Branch Name: ________________ Branch Code: ____________
Following are the documents:
In case of company account necessary board resolution obtained ⬚ Y ⬚ N
In case of partnership account necessary partnership deed obtained ⬚ Y ⬚ N
Approval enclosed for lien removal/charge reversal: Date: ____/____/_____
Name and EIN of official (As per Delegation of Financial Power) __________________________________________
Certified that this Request letter is complete in all respect & all relevant documents are obtained & verified Mode of
Operation & signatures of the A/C. The request may please be processed.

Signatures: _____________________ Designation: ________________________

Customer signed in my presence: Employee name _________________________________ EIN: _______________

Service Charge (if any) Rs. __________ ⬚ recovered ⬚ waived off

Balance in A/C: ___________________ Amount paid: ₹______________________________ Dated: ___/____/________
If paid by DD No. : ______________________ by RTGS/NEFT UTR No: _________________________________________

Customer Acknowledgment
Date: ____/____/________ Service Request No. __________________
Account Number: ⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚⬚ Account Name: ________________________________________
Employee Name: ___________________________________________ EIN: _______________

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