Door No. and Building Name Street No. and Street Name Area. Door No. and Building Name Street No. and Street Name Area. Version 3

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1 Version 3 Door No. and Building Name Street No. and Street Name Area (Mandatory if IB is opted) Door No. and Building Name Street No. and Street Name Area

2 Mandatory KYC* Aadhaar Card Number Or Aadhaar Enrolment Number Pan Available Yes No If Yes, PAN Number If No, Form 60 (If annual income less than or equal to 2.5lakhs/Agricultural Income) and Form 49A (If Non agriculture income is greater than 2.5lakhs) *If any of the above mentioned documents are not submitted within 6 months of account opening, account will be frozen, if not already submitted Additional KYC (OVD) Required Yes No I/We here by authorize the bank to debit Rs. from my/our Ujjivan account number as initial deposit. Account Statement: Physical Statement E-Statement None (Chargeable for SA, not applicable for BSBDA) Frequency: Monthly Quarterly Half-yearly Annually

3 (Mandatory only for Current account) * As the nominee is a minor on this date. I appoint, my Relationship to receive the amount of the deposit in the account on behalf of the nominee in the event of my/our/minor s death till the nominee is a minor.

4 2) Copy of Terms and condition, Service charges and Fees brochure and Fair Code of conduct can be obtained from the branch/website.

5 Declaration as per FATCA/CRS Do you have income which is taxable in any countries other than India: If Yes, mention the country If U.S., Mention the below: Do you hold U.S. Citizenship? Do you have a U.S. Green Card? Yes Yes Yes No No No If Yes, please fill FATCA/CRS Declaration *in case applicant is providing thumb impression and not the signature Name of witness: Name of witness: Signature: Signature: Address: Address:

6 Source of Lead: Self Referral Wish list Customer referral call Activity lead Branch lead SMS Campaign Cold call Others I confirm that I visited the local / mailing / correspondence address mentioned in the account opening form on --/--/----. I met the applicant / Based on the inquiries I made, I am satisfied beyond reasonable doubt that the applicant lives there (strike off what is not applicable) Paste acknowledgement taken from customer here:

7 Cheque Book

8 To APPLICATION FOR LINKING AADHAR NUMBER TO BANK ACCOUNT and CONSENT FOR AADHAAR BASED AUTHENTICATION The Branch Manager, Bank Branch Date: I... (name of the account holder) /S/w/d/0...R/0... wish to link my Aadhaar number to my proposed /Exist ing bank account number. The particulars of the Aadhaar / UID letter are as under: (self-attested copy enclosed) Aadhaar / UID number... Name of the Aadhaar Holder as in Aadhaar Card I hereby state & undertake that I have no objection in authenticating myself with Aadhaar based Authentication system and hereby give my voluntary consent as required under the Aadhaar Act 2016 and Regulations framed thereunder for seeding my Aadhaar number to my bank account & to provide my identity information (Aadhaar number, biometric information & demographic information) for Aadhaar based authentication for the purpose of availing of the banking services including operation of account & for delivery of subsidies, benefits and services or any other facility relating to banking operations. 3. I hereby give my voluntary consent in seeding my Aadhaar Number to all my existing bank accounts and to my customer profile. i. Account Number 1:... iii. Account number 3:... ii. Account Number 2:... iv. Account Number 4: I hereby authorise to use my linked Aadhaar enabled bank account for receiving Government payment across schemes that I am eligible & /or any other payment using the Aadhaar based information and NPCI may MAP my primary account in the Aadhaar Mapper of NPCI. 5. (Tick ( ) only one from below for NPCI Mapper for getting DBT benefits) o o Map my account no. at NPCI to enable me to receive Direct Benefit Transfer(DBT) from Government of India in my above account. I understand that if more than one Benefit transfer is due to me, I will receive all Benefit Transfers in this account I already have an account with another bank linked to Aadhaar and only that will be used for NPCI mapper and for receiving Direct Benefit Transfer from Government of India further request you to register my mobile number... to my above account number. SMS alerts may be sent to this mobile number. Please also register my -id. : I have been explained about the nature of information that may be shared upon authentication. I have been given to understandthat my information submitted to the bank herewith shall not be used for any purpose other than mentioned above, or as per requirements of law. 8. I hereby declare that all the above information voluntarily furnished by me is true, correct and complete. Yours faithfully [if consent sent through BC/8D0/VO] (Signature/Thumb Impression of customer) Name Fathers / Spouse Name: Account Num ber: Address of the customer: Branch Name: Bank Name' o I hereby authorise the Banking Correspondent... o I hereby authorise the Sarpanch,/ V.O./B.D.O./... to submit the above consent letter to the bank. (Signature/Thumb Impression of customer)

2. Therefore, for continued DBT to MGNREGS workers whose accounts are not

2. Therefore, for continued DBT to MGNREGS workers whose accounts are not To: 7. 2. 3. M-1201 4 / 2 / 201 -y (344637) Government '-MGNREGA of India Ministry of Rural Development (Mahatma Gandhi NREGA Division) Krishi Bhavan, New Delhi Dated: 1"July 2017 The Principal Secretary

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