____________BANK
GOLD DEPOSIT ACCOUNT UNDER GOLD MONETISATION SCHEME
APPLICATION FORM
Photo of 1st
applicant. In the
case of a minor,
photograph of
the guardian
To
The Branch Manager
_________________Branch
Photo of 2nd
applicant. In the
case of a minor,
photograph of
the guardian
GMS Account No
Date
(CPTC Certificate Number)
Dear Sir,
I/We, Name/s and address/es as given below wish to open an account under Gold Monetisation
Scheme with your branch.
We would be taking the Gold articles to _____________(Name of the CPTC) for purity testing and
assaying. I/We hereby agree that the gold deposited is subject to final assaying as determined by the
Assaying Unit of Banks authorised Collection & Purity Testing Centre (CPTC) and that the actual
weight of gold for deposit would be determined after the final assaying and expressed in grams of
gold of .995 fineness. OR
I have deposited Gold articles with ______________, a Bank authorised CPTC and their certificate
regarding quality and quantity in terms of .995 fineness gold is enclosed.
OR
(In case gold is deposited in branch)
I/We,
Name/s
and
address/es
as
given
below
hereby
deposit________grams
____________________________grams(in words) of gold as per particulars mentioned. I/We hereby
agree that the gold deposited is subject to final assaying by ______ Bank designated CPTC and that
the actual weight of gold for deposit would be determined after the final assaying and expressed in
grams of gold of .995 fineness.
1. Name of the first applicant
(Mr./Mrs./M/s)
2. Fathers/ Husbands/Guardians Name:
3. Address
(with City, State and Pin code)
4. Telephone No.
Mobile No
Email ID
5. Occupation
Professional / Self-employed
Wage / Salary earner
Retired person
Others
House Wife
Trade / Business
Agriculture
6. Date of birth (in case of minor
7. PAN / GIR No
8. Adhaar No(optional)
9. Name of the second applicant
10. Address
(with City, State and Pin code)
11. Telephone No.
Mobile No
Email ID
12. Occupation
Professional / Self-employed
Wage / Salary earner
Retired person
Others
House Wife
Trade / Business
Agriculture
13. Date of birth (in case of minor
14. PAN / GIR No
15. Aadhaar No (optional)
16. Mode of Operation (for Joint accounts)
Either or
Survivor
Former or
Survivor
17. Saving Bank / Current A/c no
with the Bank
18. Type of Deposit:
STBD Short Term Bank Deposit (years)
Medium Term Government Deposit (Years)
Long Term Government Deposit (Years)
19. Rate of Interest
20. Interest payment
MLTGD only in INR
2
5
12
3
6
13
7
14
%
Monthly
Annual (as on 31st March)
On maturity (compounded annually)
21. Repayment
STBD
In Gold
In INR
15
Joint
Guardian
a. Mode of operations (for joint accounts): Either or Survivor/Former or Survivor/Joint/guardian.
b. I / We have read, understood and agree to abide by the terms and conditions of -----Bank Gold
Monetisation Scheme.
c. I / We agree to accept the weight of gold of 995 finess as determined by the Assaying Unit of
Banks authorised Collection & Purity Testing Centre (CPTC)
d. I/We also agree that the Certificate will be redeemed in INR or in gold of 995 fineness and not in
the original form it was tendered by me/us.
e. I/We agree to pay any fees charged by the CPTC, in case, I/We decide not to place gold deposit
after initial XRF test or after melting and fire assay test.
f. I/We hereby declare that the gold deposited herewith by me / us belongs to the first applicant and
it does not have any ornamental / antique value.
g. I/We confirm that I / we am/are the owners of the gold deposited by me/us. I/We declare that my
/our title to the gold deposited by me/us is not defective / challenged by any person in any form
nor is it spurious. The gold has been acquired by me / us from genuine sources, is genuine gold
and is my / our bonafide property and no other person has any claim, lien or charge against it
h. Details of gold tendered are as under (use additional sheet if necessary)
SI
No.
Description of Gold (bars, coin,
jewellery tendered as scrap)
No of
Pieces
Weight of Gold
(in gms, upto 3
decimals)
Purity of Gold (as
per preliminary
surface purity
testing)
(to be filled up only in respect gold
accepted by the bank directly at their
discretion)
Total
*As weighed at the Bank in presence of the customer.
Nomination
Nomination form submitted
Signature(s) of
Tenderer(s)
(Affix property seal in case of
Trust / Company)
First Applicant
Yes
Second Applicant
For Office use only
(applicable only if gold is accepted directly at the branch)
Deposit as above accepted.
Provisional Certificate No.
issued
Authorised Official
Date Stamp
No
--------- BANK
---------- BRANCH
---------- BANK MONETISATION SCHEME (GDS)
Provisional Receipt No (applicable incase the Gold is deposited in the Bank)
Received scrap gold under Application date_________________ from Mr/Mrs/M/s ___________
_____________________________________________________________________________
_________________________________________________________________________________
(Name and address of the First Applicant)
As per the particulars given below, for issue of Gold Monetisation Certificate
SI
No.
Description of Gold (bars, coin,
jewellery tendered as scrap
No of
Pieces
Weight of Gold
(in gms, upto 3
decimals)
Purity of Gold (as
per preliminary
surface purity
testing)
Total
Above scrap gold will be subject to final assay by melting and the result of the final assay will be
binding on the applicant. Gold Mobilisation Certificate will be issued based on the final assay report, a
copy of which will be held by the Bank.
This Provisional Receipt is not transferable and will be invalid after the Gold Monetisation Certificate
issued.
Signature:
Signature:
Name:
Name:
Designation:
Designation
Date:
(Stamp of the Receiving Branch)
