STATE BANK OF INDIA

FINANCIAL INCLUSION ACCOUNT

OPENING FORM
Reference Number: Date:
SBI525510434969 12/09/2025

Name of the Branch BAWAN

Village/Town Jagdishpur

Sub District/Block Name Ward No.:

District Hardoi State: UTTAR PRADESH

Village Code /Town Code Name of Village/Town

0915500811139999 Jagdishpur
[as per census 2011] [as per census 2011]

EKYC Certificate Number SBI525510434969 CKYC Number

CIF Number 92244251522 Account Number 44463862437

Name Shivani Shivani

Date Of Birth 01/01/2002

Gender Female

Marital Status Married

Father Name SUSHIL X

Spouse Name (If married) nishant sharma sharma

Mother's Name SUNITA DEVI

Nationality IN-Indian others (ISO 3166 - Country Code)

Citizenship Indian Number of Dependents 0

Place Of Birth jagdishpur Maiden Name

Religion Hindu Designation/Profession

Caste General

S-Service Private Public Government Sector

Occupation type Self- Retired House Wife

O-others Professional
Employed Student

B-Business
PAN / Form 60 Mandatory.If
customer provides PAN ,PAN
Details to be captured.If
NA Name Fetched From NSDL NA
customer provides Form 60,
capture below mentioned
data

Date of FORM60 submission Aadhaar

12/09/2025 Transaction date 12/09/2025 XXXXXXXX2012
by customer Number if given

Income from Income from

Annual Income Rs.80000 Rs.0000 Rs.80000
Agriculture other sources

PAN Applied but not yet

NO
generated flag

Acknowledgement no for
Date of PAN Applied NA PAN Applied NA

Residential Status India

ISO 3166 Country code of

IN - India
country of Tax residense

Current Address:C/O: Nishant Sharma Gram Jagdishpur Post Saitiyapur Hardoi UTTAR
PRADESH
Address Pin code:241001
Communication Address:C/O: Nishant Sharma Gram Jagdishpur Post Saitiyapur
Hardoi UTTAR PRADESH

Mobile No. XXXXXX3695

DVD/KYC Document Type Aadhaar Card(UID) with same address XXXXXXXX2012

Deemed OVD

I request you to issue me a

YES
Rupay card.

CKYC Expiry Date 12/09/2035

I, the holder of Aadhaar number XXXXXXXX2012, 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.

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 Shivani Shivani hereby apply for opening of a Bank Account. I declare that the information provided by me in this application
form is true and correct. I also declare that I do not have any other SB account with SBI/Other Bank The terms and conditions
applicable have been read over and explained to me and have understood the same

PLACE: BAWAN
DATE:12/09/2025
Signature / Thumb Impression of Applicant

Nomination:
I want to nominate as under

Person authorized in case to receive the amount of

Name of Date of Birth in Mobile No of
Relationship Age deposit on behalf of the nominee in the event of
Nominee case of minor Nominee
my/minor(s) death.

NISHANT HUSBAND 31 NA

OR

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

Date:12/09/2025

Place:BAWAN
Signature / Thumb Impression of Applicant

Witness-1 Witness-2
Name: Name:
Address: Address:
DateofBirth: DateofBirth:
 Form No. 60 (See second provision to rule 114B)

Verification
I, Shivani Shivani 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, minor
child etc. as per section 64 of Income-tax Act, 1961) computed in accordance with the provisions of Income-tax Act, 1961 for
the financial year, in which the above transaction is held will be less than maximum amount not chargeable to tax.

Verified today, 12/09/2025

PLACE: BAWAN
Signature / Thumb Impression of Applicant

Witness-1 Witness-2

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

SIGNATURE :
KO NAME:- Mr. DELEEP KUMAR
KO CODE:- 1A7973131
FOR OFFICE USE AT BC/CSP LEVEL
NAME:- Mr. DELEEP KUMAR
CSP CODE:- 1A7973131

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 :-