AGRI COMPOSITE LOAN : APPLICATION FORM

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Colleen Johns
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1 To, Branch Name : Branch Code : CUSTOER ID : Savings A/C No. : Date : D D Y Y Y Y The Branch anager, UJJIVAN SALL FINANCE BANK, BRANCH, AGRI COPOSITE LOAN : APPLICATION FOR I/We hereby request you to grant me/us a loan of Rs. (Rupees only) for the purpose of: AGRI ACTIVITY FUNDING ACTIVITY DETAILS Dairy aintenance Purchase Off Farm Off Farm Activity (Please mention activity here) Core Farm Implements (Purchase) Second Hand Tractor Other Implements (Please mention name of the implement) Post Harvest Transportation (Vehicle Purchase) Toto Vehicle inidor Pick Up Van Poultry Equipment Purchase Farm Development Sericulture Equipment Purchase Farm Development Sheep Rearing aintenance Purchase ushroom Equipment Purchase Farm Development Coconut Equipment Purchase Farm Development Supplementary Bee Farming Equipment Purchase Farm Development Floriculture Equipment Purchase Farm Development Please select the flower type: Button Rose Tube Rose Jasmine Vegetable (Farm Dev + Equip Purchase) Equipment Purchase Farm Development Please select the vegetable combination: Tomato Brinjal Chilli Onion Gourd Pumpkin Carrot Raddish Potato Cabbage / Cauliflower Leafy Vegetables

2 BASIC DETAILS: PARTICULARS APPLICANT CO APPLICANT Photo (Cross Sign Photo) Paste PHOTO here Paste PHOTO here CIF ID Name (Customer Name should be as per UID) r / s r / s Gender ale Female Third Gender ale Female Third Gender Father's Name other's Name r. s. arital Status Single arried Unmarried Widowed Separated Religion Hindu uslim Sikh Christian Buddhist Others r. s. Single arried Unmarried Widowed Separated Hindu uslim Sikh Christian Buddhist Others Category General SC ST General SC ST OBC Others OBC Others Education ualification Illiterate atriculate Graduate Illiterate atriculate Graduate Post Graduate Others (Specify) Post Graduate No. of Dependents NA Others (Specify) Farmer Category arginal Small Big Landless Agricultural Labourer Others Current Address House/ Door No Street/ Area Name City/ Town / Village District State Pincode Landmark Permanent Address obile Number Alternate Number Same as Current address House/ Door No Street/ Area Name City/ Town / Village District State Pincode Landmark Same as Applicant address House/ Door No Street/ Area Name City/ Town / Village District State Pincode Landmark Account Details : Ujjivan Account Type: Self Joint Beneficiary Name Bank Name Branch Name Account No IFSC Code

3 PARTICULARS APPLICANT CO APPLICANT No. of Years of Stay in the Home Address No. of Years in Agri Activity Nominee Details (Life Insurance) Name Age D.O.B Relationship NA NA Applicant will be the nominee for co-applicant in all cases KYC DETAILS: PARTICULARS APPLICANT CO APPLICANT Aadhar Card PAN / Form 60 Other KYC Type of ID Type of ID Date of Birth D D Y Y Y Y DOB Age Proof Aadhar PAN Other KYC D D Y Y Y Y DOB Age Proof Aadhar PAN Other KYC PARTICULARS OF ASSETS OWNED 1.Land Village Name Survey No Total extent of land (Acre) Irrigated/ Dry Source of Irrigation Encumbrance (If Any) Owned/ Leased If on lease, the Lease Period Date of commencement of lease Value 2. Other Assets PARTICULARS DESCRIPTION NO. VALUE Livestock Tractor or Other Farm Implements Other Investments (like NSC, LIC, Shares)

4 A. Cash Flow Analysis: Total Household Income S. No Name Relationship Income Type Income Generating Activity Cash Flow Type Nett Income 1 2 Funding Activity Income Other Agri Income 3 Non Agri Income Total onthly Income Total uarterly Income Total Half Yearly Income B. Household Expenses Food (onthly) Education (onthly) Transportation (onthly) Others (onthly) Total onthly Expense (Agri ()+ All )

5 C. Household Borrowings Borrower (App/ Co App) Source of Borrowing Loan Purpose Amount Borrowed Instalment Amount Loan Tenor Current Balance D. Disposable Income Frequency Total Income (A) Total expenses (B) Borrowings (C) Disposable Income LOAN REUIREENTS Activity Type Funding Activity Loan Purpose Breed / ake / HP /Crop No. of Units Cost argin (if App) Loan Amount Required EI Core 1 Core 2 Supplementary 1 Supplementary 2 Supplementary 3 Total POTHECATION DETAILS Hypothecation of crops cultivated in Acres, Survey. No Village Valued at Rs. Hypothecation of Existing / Proposed Assets financed by bank Valued at Rs.

6 DECLARATION 1. I/We hereby declare that particulars given above are true and correct to best of my/our knowledge. 2. I / we shall abide by the terms and conditions of the bank in respect of the proposed loan and I/we shall furnish to the bank all the particulars required by the bank from time to time. 3. I/ We hereby authorise the bank to disclose all or any particulars or details of information relating to my/our loan account with the bank to any other financial institution / govt. / any agency/ IES the bank's subsidiaries/affiliates and or third parties for official and/or administrative purposes, as and when necessary without any further notice to me/us. 4. I/ We declare that we have no borrowings from any other agency as on date of application other than the details furnished. It will be in order for the bank to disqualify me/us from receiving any credit facilities from the bank in case it is proved that declaration of my/our outside borrowings above contains misrepresentation of facts. Also, the bank shall have the right to take any legal action against me/us in case of any loss to it by such fact. I/We shall not borrow from any other banks/fis without the permission of the bank. 5. I/We hereby agree as a precondition of the loan / advances given to it by the bank that in case the borrower/s commit/s default in the repayment of interest thereon and any of the agreed instalment of the loan on the due date/s, the bank or RBI will have an unqualified right to disclose or publish its name/s and its directors/ partners/ proprietors as defaulter in such manner and through such medium as the bank or RBI in their absolute discretion may think fit. 6. I/We undertake to utilise the loan amount for the purpose for which it is granted. 7. I/We permit any member staff of the bank to inspect equipment, other properties owned /purchased out of bank's assistance or which are charged to the bank until full repayment of the loan that may be granted. I/we shall furnish to such member staff of the bank all the particulars and information about the equipment / properties desired by them. 8. Aadhaar Consent: I/We, the holders of Aadhaar number hereby give my/our consent to the bank to obtain my/our Aadhaar number, name and finger print/iris for authentication with Unique Identification Authority of India ( UIDAI ). The bank has informed me/us that my/our identity information would only be used for e-kyc purpose. The bank has also informed me/us that my/our biometrics will not be stored/shared and will be submitted to Central Identities Data Repository ( CIDR ) only for the purpose of Authentication. 9. Credit Bureau Check: I/We authorize the bank to use the details provided by me/us in the Customer Profile Form/Loan Application Form for credit bureau enquiries. The bank has informed me/us that after closure of my/our existing loan, subject to me/us maintaining healthy financial discipline, the bank may consider granting repeat loan to me/us at the pure discretion of the bank, if I/we give consent to the bank to access the database of Credit Information Companies or such other repositories. I/We hereby expressly give consent to / not giving consent to the bank to access the database of Credit Information Companies or such other repositories, for a period of 60 (Sixty) days from the date of closure of my/our then existing loan, for obtaining my/our credit information, and I/we shall not at any time raise any objection or dispute or claim against the bank or its officials if it accesses the database of Credit Information Companies or such other repositories for obtaining my/our credit information within the above mentioned period. 10. Central KYC: I/We hereby expressly consent the bank to upload/share with Central KYC Registry my/our KYC data provided to the bank through the Customer Profile Form/Loan Application Form. I/We also hereby consent to receive information from Central KYC Registry through SS/ on the said mobile number/ Id. 11. DND/NDNC: I/We consent do not consent to the bank for de-registering my contact number in the 'Do Not Call Registries' (DNCs) and also to deactivate/de-register DND status of my contact number. I/We am/are aware that post de-registration of DND/NDNC, I/we may receive a call from the bank to verify the correctness of request for registration. The bank is authorized to use my/our contact number/ Id mentioned in the Customer Profile Form/Loan Application Form in connection with transactional, promotional as well as service related calls or messages, through Telephone/obile/SS/ by the Bank or its Agents. 12. Insurance: I/We am/are aware that the Loan is eligible to be covered under Group Loan Insurance administered by the bank. I/we Agree Disagree to opt for such Insurance offered by the concerned Insurer with whom the bank has tie up, for insuring myself/ourselves and my/our spouse(s). I/We have read and understand the insurance product features, benefits and risk factors, structures of charges, terms and conditions of the insurance products of the Insurer and the bank has at no point of time compelled me/us to avail insurance from the Insurer. 13. I/We agree that we have understood the terms and conditions mentioned above Name & Signature of the Applicant Name & Signature of the Co - Applicant Date: D D Y Y Y Y Place: I have verified all the data within this form and have performed due diligence as prescribed in the product policy. I approve / reject this customer for further loan processing. Signature: LO Name: LO ID:

Name of the Bank... Branch... LOAN APPLICATION FORM FOR AGRICULTURAL CREDIT. (Production Credit/Crop Loans/KCC/Agri-Term Loan)

Name of the Bank... Branch... To: The Branch Manager... LOAN APPLICATION FORM FOR AGRICULTURAL CREDIT (Production Credit/Crop Loans/KCC/Agri-Term Loan) A. For Office Use: Application Sl. No. Category SF