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STATE BANK OF INDIA
FINANCIAL INCLUSION ACCOUNT
OPENING FORM
Reference Number :27264601592 Date: 19/07/2025
Name of the Branch JODAURA SITAPUR
Village/Town Kandhaimahimapur
Sub District/Block Name Sidhauli Ward No.:
District Sitapur State: UTTAR PRADESH
Village Code /Town Code Name of Village/Town
0915400808138965 Kandhaimahimapur
[as per census 2011] [as per census 2011]
EKYC Certificate Number SBI509512681796 CKYC Number
CIF Number 92076188842 Account Number 43976755157
Name Nijamuddin Nijamuddin
Date Of Birth 01/01/2006
Gender Male
Marital Status Single/Unmarried
Father Name SRI DASTGEER
Spouse Name (If married)
Mother's Name NAFEESHA NAFEESAHA
Nationality IN-Indian Others (ISO 3166 -Country Code)
Number of
Citizenship Indian 1
Dependents
Place Of Birth KANDAIMAHIMAPUR Maiden Name
Designation/
Religion Muslim
Profession
Caste OBC
PAN / Form 60 Mandatory.If
customer provides PAN ,PAN Details
to be captured.If customer provides Name Fetched From NSDL
Form 60, capture below mentioned
data
Date of FORM60 Aadhaar Number if
09/08/2024 Transaction date 05/04/2025 XXXXXXXX3595
submission by customer given
Income from Income from
Annual Income Rs.28000.0 16000 12000
Agriculture other sources
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PAN Applied but not
NO
yet generated flag
Applied
Date of PAN Applied Acknowledgement no
for PAN Applied
Residential Status India
ISO 3166 Country
code of country of Tax IN - Indian
residence
Current Address: S/O: Dastgeer kandai mahimapur, po.rampurkalan, Kandhaimahimapur, , Saraiya
Raja Sahab, UTTAR PRADESH
Address PIN Code:- 261206
Communication Address: S/O: Dastgeer kandai mahimapur, po.rampurkalan, Kandhaimahimapu
r, , Saraiya Raja Sahab, UTTAR PRADESH
Mobile No. 8176830396
OVD/KYC Document
AADHAAR CARD(UID) WITH SAME ADDRESS:XXXXXXXX3595
Type
Deemed OVD
I request you to issue
YES
me a Rupay Card.
CKYC Expiry Date 18/04/2029
I, the holder of Aadhaar number XXXXXXXX3595, 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.
2.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.
3.Use my Aadhaar details to authenticate me from UIDAI.
4. 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').
5.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.
6.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
7. 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.
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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/informationknown 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.
14. I, hereby, provide my consent to register for performing AePS transactions.
Declaration
I Nijamuddin Nijamuddin hereby apply for opening of a Bank Account. I declare that the information provided by me in this app
lication form is true and correct. I also declare that I do not have any other SB account with SBI/Other Bank The terms and con
ditions applicable have been read over and explained to me and have understood the same
PLACE: JODAURA SITAPUR
Signature / Thumb Impression of Applicant
DATE: 07/08/2025
Nomination:
I want to nominate as under
Name of Date of Birth in case Mobile No of Person authorized in case to receive the amount of deposit on b
Relationship Age
Nominee of minor Nominee ehalf of the nominee in the event of my/minor(s) death.
DASTGEE
FATHER 50 01/01/1975
R
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OR
I do not want to nominate any person in this account.
Date: 07/08/2025
Signature / Thumb Impression of Applicant
Place: JODAURA SITAPUR
Witness-1 Witness-2
Form No. 60(See second proviso to rule 114B)
Form for declaration to be filed by an individual or a person (not being a company or firm) who does not have a permanent acco
unt number and who enters into any transaction specified in rule 114B
Verification
I, Nijamuddin Nijamuddin do hereby declare that what is stated above is true to the best of my knowledge and belief. I further
declare that I do not have a Permanent Account Number and my / our estimated total income (including income of spouse, min
or child etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 fo
r the financial year, in which the above transaction is held will be less than maximum amount not chargeable to tax.
Verified today, the 07 day of Aug 2025.
PLACE: JODAURA SITAPUR
Signature / Thumb Impression of Applicant
Witness-1 Witness-2
Name: Name:
Signature: Signature:
Address: Address:
SIGNATURE :
KO NAME:-SHAILENDRI YADAV
FOR OFFICE USE AT BC/CSP LEVEL KO CODE:- 1B021189
NAME:- LAVKUSH KUMAR
CSP CODE:- 1B021189A
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FOR OFFICE USE AT LINK BRANCH
Particulars of a/c opened tallied with a/c opening form
Account No.
Signature of BM at Link branch
Card No.
SS NO :-
Date :-
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