Joint Liability Group (JLG) Loan Cum Account Opening Form

1 Joint Liability Group (JLG) loan Cum Account Opening FormFor Bank Use Only (* Fields are Mandatory)Application No.: INDC ustomer ID: Account No.:Please affix a recent photographandSign across the photoBranch:SOL Code:Date:YYYYMMDDO ccupation Code:*Segment CodeAccount Statement Delivery Mode: Printed Statement on Quarterly BasisAddress DetailsCurrent Address:Permanent Address: Same as Current AddressCityPINS tateCountryMobile NumberDistrict Code:CityPINS tateCountryMobile NumberDistrict Code:Customer Information(First Name)(Middle Name)(Last Name)Maximum 32 characters.*Name:Existing Customer ID:(If applicable) * Account Type:NormalSimplified (for low risk customers)SmallOTP based e-KYCKYC Number:*Mother s Maiden Name:*Date of Birth:YYYYMMDDE xpiry Date:YYYYMMDDD riving Licence:*Aadhaar Number:Voter Identity Card:*Spouse Name:*Father's Name:*Mother s Full Name:Marital Status:MarriedUnmarriedWidowDivorcedOthe rEducational Qualification:Illiterate10th and belowIntermediateGraduatePost GraduateReligion: HinduMuslimChristianSikhBuddhistJainPars iOthers* Person:YesNoCategory:GeneralOBCSCSTO thersMBCP lease fill FATCA Declaration Form if you are or other country citizen / resident*Country of Birth:*Place of Birth:Citizenship:*Residence for Tax Purposes:Number of Dependents:Annual Income: `Annual Family Expenses.

2 `Land Holding:Landless_____ AcresResidence:Self OwnedFamily OwnedRentedTwo WheelerVehicle:Four WheelerBothNoneForm 60 Permanent Account Number (PAN):*Gender:MaleFemaleThird Gender*Status:MinorSr. CitizenGeneral*Nationality:IndianOther (please specify)Source of Funds for Credits in the Account : loan AmountSavingsSalaryOther (please specify)Risk Classification:Politically Exposed PersonOther (please specify)Risk Classification of Account (Low / Medium / High):(* Fields are Mandatory)NREGA Job Card:Please fill the form in "BLOCK LETTERS" :Signature:Address:Place:Date:Name:Signa ture:Address:Place:Date:Nomination Details (Form DA 1)Yes, I want to nominate the following personNo, I do not want to nominate anyoneAddress:Nominee Name:YRelationship with Applicant, if anyYYYMMDDDate of Birth:YearsAge:* As the nominee is a minor on this date, I / we appoint (Name & Address)*Strike out if nominee is not a minor.

3 ** Where deposit is made / Account is held in the name of the minor the nomination should be signed by a person lawfully entitled to act on behalf of the (es):to receive the amount of the deposit / in the Account on behalf of the nominee in the event of my /our death during the minority of the case you have specified a nominee above, please indicate if you wish to make mention of the nominee name in the statement & DCA issued in respect of your / We do hereby declare that what is stated above is true to the best of my / our knowledge and / Thumb Impression of depositorI / we nominate the following person to whom in the event of my / our / minor s death the amount of the deposit / in the Account may be returned by DCB Bank LimitedNominationunder Section45ZA of the BankingRegulation Act, 1949 and Rule 2(1) of the Banking Companies (Nomination)

4 Rules 1985 in respect of impression isrequired to beattested by2 case of signature, nowitness Details / loan RequirementsI member of _____ ( Group name) and Centre _____ (Centre Name) would like to apply for a loan of ` _____ (in numerals) _____ (in words) from DCB Bank Limited for the purpose as mentioned under loan purpose and below mentioned loan tenure and repayment Tenure:MonthsRepayment Frequency:Rate of Interest:.%Purpose of loan :Please Specify:Agriculture and Allied ActivitiesSmall Economic ActivitiesCredit FacilitiesI enjoy credit facilities with other entity/ies and the details are as below: I do not enjoy credit facilities with other entity/iesEntity/iesName of the FacilityLimitROIT enureStatusActiveClosedActiveClosedPleas e contact DCB 24-Hour Customer Care to enquire about your Account application Bank LimitedM063 / Sep 18 / September 2018 Form No.

5 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 Account and who enters into any transaction specified in rule 114B (First Name)(Middle Name)(Last Name)2. Date of Birth / Incorporation of Declarant:YYYYMMDD(First Name)(Middle Name)(Last Name)1. Father's Name (in case of individual):4. Flat / Room No.:6. Name of Premises:7. Block Name / No.:8. Road / Street / Lane:16. Amount of Transaction (`):17. Date of Transaction:YYYYMMDD5. Floor No.:9. Area / Locality:10. Town / City:11. District:12. State:13. PIN Code:14. Telephone Number (with STD code):15. Mobile Number18. In case of transaction in Joint names, number of persons involved in the transaction:19.

6 Mode of Transaction:CashChequeCardDraft / Banker's ChequeOnline TransferOther20. Aadhaar Number issued by UIDAI: (if available) 21. If applied for PAN and it is not yet generated enter date of application and acknowledgement number YYYYMMDD22. If PAN not applied, fill estimated total income (including income of spouse, minor child etc. as per section 64 of Income-tax Act, 1961) for the financial year in which the above transaction is helda. Agricultural income ():`b. Other than agricultural income ():`23. Details of document being produced in support of identify in Column 1 Document code Document identification number Name and address of the authority issuing the document24. Details of document being produced in support of address in Columns 4 to 13 Document code Document identification number Name and address of the authority issuing the document Verification I, _____ do hereby declare that what is stated above is true to the best of my knowledge and belief.

7 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, the _____ day of _____ 20_____ Place: _____ (Signature of Declarant) Note:1. Before signing the declaration, the declarant should satisfy himself that the information furnished in this form is true, correct and complete in all respects. Any person making a false statement in the declaration shall be liable to prosecution under section 277 of the Income-tax Act, 1961 and on conviction be punishable;(i)in a case where tax sought to be evaded exceeds twenty five lakh rupees, with rigorous imprisonment which shall not be less than six months but which may extend to seven years and with fine; (ii) in any other case, with rigorous imprisonment which shall not be less than three months but which may extend to two years and with fine.

8 2. The person accepting the declaration shall not accept the declaration where the amount of income of the nature referred to in item 22b exceeds the maximum amount which is not chargeable to tax, unless PAN is applied for and column 21 is duly filled. Name of Bank Official / Authorised Business Correspondent officialAcknowledgement0159236 Please provide this number for future referenceI acknowledge receipt of application for loan of ` _____ on _____ (Dated) from _____ (Customer Name) under DCB Bank Limited JLG Program subject to verification of contents and enclosure (if any). DCB Bank will endeavor to inform you about the status of your application normally within 15 working days from the date of receipt of documents / information as required from time to time and furnished by you to DCB Bank of Bank Official / Authorised Business Correspondent officialEmployee Id of Bank Official / Authorised Business Correspondent officialDeclarationI hereby apply for Opening a Savings Bank Account and loan Account under Joint Liability Group (JLG) Model.

9 I am aware that the Account will be operated by myself only. I have read and understood the terms and conditions applicable to this Account and I agree to the terms and conditions as may be in force from time to time. I also understand that Account Opening is subject to KYC clearance by DCB Bank Limited ( DCB Bank ). I shall abide by KYC norms as stipulated from time to time. I accept that DCB Bank has the discretion to accept or reject this application without assigning any reason further authorize DCB Bank to debit my Account towards any applicable charges for any / various service / services provided as applicable from time to time. I understand and agree that the consent given for updation / registration / requests for free Mobile alert facility shall be valid till such time I withdraw the same in understand, accept, acknowledge, agree, confirm and declare: (a)That all the particulars and information given in this application form (and all documents referred or provided therewith) are true, correct, complete and up-to-date in all respects and I have not withheld any information.

10 I understand certain particulars given by me are required as per the operational guidelines governing banking companies. I agree and undertake to provide any further information as and when DCB Bank may require. (b) That I have had no insolvency proceedings initiated against me nor I have ever been adjudicated insolvent. (c) That DCB Bank reserves the right to reject my application without providing any reason and reference to me. I agree and understand that DCB Bank reserves the right to retain the application forms and the documents provided therewith, including photographs, and shall not return the same to me. (d) To inform DCB Bank regarding change in my residence /employment and to provide any further information as and when DCB Bank may require from time to time.