7/ 16/ 2019 Asset s Li abiliti es St at ment s - F - 349 f or Guar ant or

a/c F - 349 for Guarantor

INDIAN OVERSEAS BANK

Branch:

ASSETS & LIABILITY STATEMENT

From To
The Branch Manager
Indian Overseas Bank
Branch:
Date :

Dear Sir,
Ref. : Application for credit facility submitted
by M/S
for Rs.
.......................................................................................

With reference to the above loan application, I furnish hereunder my

personal information and details of my Assets and Liabilities in Table A and Table
D. I also enclose copies of my Tax Returns / Assessment Order / Salary Certificate /
Encumbrance Certificate of my property for your record.

I hereby declare that the particulars furnished by me hereunder are true to the best of my
knowledge.

Yours faithfully,

Signature

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7/ 16/ 2019 Asset s Li abiliti es St at ment s - F - 349 f or Guar ant or

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TABLE : A-- PERSONAL INFORMATION

A.1 NAME
A.1a Dt. of Birth & Age
A.2 Father ’s Name / Hus band’s Name
(in case of Married women)
A.3 Res idential Address & Tel.
No. A.4 Office Address & Tel. No.
A.5 PAN & IT Circle
A.6 Name of Employer / Nature of
Business / Profession

A.7 Position held now

A.8 Particulars of Previous employment, if
any
A.9 Monthly Emoluments (if in service)
Cross Income LESS Deductions Net Emoluments
Per Month Rs. Per Month Rs. per Month Rs.
1. 2. 3.

A.10 Earning From Profession/Business

Gross Income Less Expenses Net Earning
Per Annum Rs. Lac
Per Annum Rs. lac Per Annum Rs. Lac
1 2 3

A.11 Name, Address & Tel. No. of my :

present Banker
A.12 Details of Guarantee already executed by me
Name of Principal Name of Guarantee Guarantee Valid Remarks
Debtor Beneficiary Amount upto

1 2 3 4 5

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A.13 Details of Credit Cards held

Name of Bank Card Limit Nature of Card Dues as on date
1 2 3 4

TABLE : B ASSETS

B. 1 Immovable properties

S.No. Name of the Owner Depreciation Location/Address of Extent of

of Property property (please furnish lan
full details with survey No.
Door No. etc.)
1 2 3 4 5
1.
2.
3.
4.
Extent of Building Type of property i.e. whether Details of Date of purchase
area residential / agricultural / documents of property
constructed Industrial / commercial, etc., conferring right
6 7 8 9

Original Purchase cost Present market value Details of encumbrances, if

Rs. Lac Rs. Lac any, on the property
10 11 12

Total
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B.2 Machineries

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Installed at Short Book Value Depreciated Appr. Encumbrance

descrip Rs. value Market of any
tion Lac Rs. Lac Value Rs. Lac

1 2 3 4 5 6

B. 3 Deposits held with companies / others

S. Name of the company Nature of Deposit Amount
No. Rs. lac
1 2 3 4

B. 4 Life Insurance Policies

Date of Poli cy No. Whether Endowment Annual Sum Surrender

policy policy or while life premium Assured Value
policy or other Rs. Rs. Lac (Rs. Lac)
1 2 3 4 5 6

TOTAL

B. 5 Govt. Securities / NSCs / Shares of Listed Companies

S. Description of Security Face Value Market Value

No. (Rs. lac) (Rs. Lac.)
1 2 3 4
1
2
3
4

5
6
7
8
9
TOTAL
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B.6 Investments in Business

Sl. No. Name of the company / firm / concern Amount invested
in which investment is made (Rs. Lac)
1 2 3
1
2
TOTAL

B.7 Depos it s h eld wi th Banks

Sl. No. Name of the Bank Nature of Deposits held Amount Deposited
(Rs. lac)
1 2 3 4
1
TOTAL 0.20

B.8 Vehicle Owned

Description of Regn. No. Original Depreciated Appr. Market
Vehicle Cost (Rs. lac) Value (Rs. lac) Value Rs. lac
1 2 3 4 5

Insurance company RC book in the name of Encumbrance if any

6 7 8

B. 9 Other Assets Owned

Sl. Nature Description of Original Cost Depreciated Approximate Encumbrance

No. assets Rs. lac value Market Value if any
Rs. lac Rs. Lac
1 2 3 4 5 6
1
2
TOTAL

B.10 TOTAL ASSETS (B.1 TO B.9) : Rs. lac

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TABLE : C LIABILITIES

C.1 Borrowings from Banks and Financial Institution

Nature of the Details of Nature & extent of credit limit / Details of
Institution / Bank facilities enjoyed securities furnished
Nature of Cr edit facilities Extent (Rs. lac)
1 2.1 2.2 3

C.2 Borrowi ngs fro m o thers

Name of the Lender Amount borrowed (Rs. lac) Details of securities

furnished
1 2 3

C.3 Other Liabilities

Nature of liabilities Extent of liabilities
(Rs. Lac)
1 2

C.4 TOTAL LI ABI LITI ES (C.1 TO C.3) : Rs . Lacs

TABLE: D NETWORTH

TOTAL ASSETS TOTAL LIABILITIES NET WORTH

D.1 Rs lacs D.2 Rs. Lac (D.1 minus D.2) Rs.

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TABLE E : DECLARATION AND UNDERTAKING

E.1 I hereby declare that the assets referred above (Table : B) are owned by me
and these assets are not alienated or encumbered except to the extent furnished in
the statement.

E.2 Further I hereby undertake, not to encumber / alienate the said assets
without prior intimate to Bank in writing till all my obligations to Bank
are fully discharged.

E.3 I/We also declare that I am not facing any litigations initiated by other
banks/ financial institutions and there are no recovery proceedings for arrears of
Income Tax, Sales Tax, Customs duty, Excise duty etc. I declare that
neither any insolvency / winding up proceedings nor any court case is pending
against me in my capacity either as borrower or as guarantor.

(pIenncdainseg,atnhye lditeitgaaitlisotnhewreitohf osthhoeur lbdabnek fiusrfnaicsehdedo)r

winding up proceedings / court case is
Nature of Litigation Brief Particulars
1 2

Nil

E.4 I am agreeable to the condition that your Bank will have unqualified right
to disclose / publish my name is such manner and through such medium as the
bank in their absolute discretion may think fit in the event of default by myself.

Date :
Place: Signature of Applicant

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TABLE : F FOR BRANCH USE

1.1 We certify that we have verified the information furnished above, with

the rtoeltahtievbeersetcoofrdosurwkhneorwevlerdgiteias nadppbleilciaebf.le

and the assessment made is true and fair

1.2 Copies of supporting documents as listed here below have been obtained and
held as branch record.

S.No. List of documents / Papers received

1.
2.
3.

4
5.

Any other remarks:

Signature of the Branch Manager.

Branch ………………………..

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