ONLINE ACCOUNT OPENING / APPLICANT INFORMATION FORM FOR RESIDENT INDIVIDUALS

Reference No. 23071116185630173833 Customer ID. Account No.

Account Scheme SBGEN Purpose of Account Online Account Type Lead Id

Account

1. Applicant Details:

Title Full Name

Mr. Arghyadeep Panda

Father's Name Asim Panda

Mother's Name Susmita Panda

Date of Birth Gender Married Spouse Name Maiden Name Ex-service Man PAN No.
05/01/2002 Male Single Y HHWPP3702A

Residential Status Place of Birth Country of Birth Physically/visually handicapped Aadhaar No.
RESIDENT INDIAN Kolkata INDIA Y 593581258460

Occupation UNDERGRADUATE Code SU001

Education Nationality Religion Caste Village Code

INDIAN HINDU GENERAL

Name of Employer / Profession / Nature of Business / Industry

2. Communication / Residence Address:

5H, Bidhan Nagar Road, 1st floor

Near Rayan's Muscle Unit

City/District KOLKATA State WEST BENGAL Country INDIA

Pin 700067 Phone No. Mobile No. 9804717466

E-mail ID [email protected]

3. Permanent Address:

144/1, Bidhan Nagar Road, Kolkata- 700067

Near Muchibazar Market

City/District KOLKATA State WEST BENGAL Country INDIA

Pin 700067 Phone No. Mobile No.

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4. Know Your Customer (KYC) Details:
KYC Number (If any)

Attach the copies of the documents opted for and produce the original copies of these documents for verification.

Code Document Identification No. Date of Expiry Issuing Authority Place of Issue
Identity Proof: ID108 593581258460

Code Document Identification No. Date of Expiry Issuing Authority Place of Issue
Residence Proof:

Annual Family Income Less than Rs. 50,000 Source of Income Others

Net Worth Less than Rs. 10 Lacs

5. Information on Credit Facilities Availed:

I Arghyadeep Panda further undertake that:

I do not enjoy credit(Fund based/Non fund based) facility with Union Bank/other Bank/s OR

I enjoy credit facility/have current accounts with Union Bank/other Bank/s and the details are as under

Vehicle loan Housing loan Consumer loan Educational loan Business loan Credit Card

Name of the Bank & Branch Account No. Facility Amount

6. Facilities Required:

Please tick in the respective boxes if you wish to avail the following facilities
Account Type Regular Gold Platinum Privilege

Y Cheque Book Collect from Branch Y Dispatch to my communication address

Statement by E-Mail Y Mobile Banking Y Debit Card Y Nomination Required Y SMS Alerts Required

Sweep-in-facility: Please clear my Cheque/allow withdrawal by transferring funds from my Saving/Current A/C No.

Foreign Remittances expected Country Code No.

7. Information details required under Tax Laws:

If the individual is tax resident in more than one country then below information may be repeated for all such countries

S.No. Date of document collected Country of Residency for Tax purposes Tax Identification Number(TIN)/ or functional TIN issuing country
equivalent

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8. Declaration/Undertaking:

1. I Arghyadeep Panda certify that I have declared my status as per the applicable FATCA/CRS rules in India as notified by Government of India (GOI) /Central
Board of Direct taxes (CBDT) /Reserve Bank of India (RBI)/in this regard.
2. I certify that the information stated in the account opening form and the supporting documentary evidence provided by me is, to the best of my knowledge and belief true,
correct and complete and that I have not withheld any material information/document, that may affect the assessment/categorization of the account at a US Reportable
account/Other Reportable account or otherwise.
3. I undertake the responsibility to declare, disclose and recertify within 30 days any changes that may take place in the information provided in the account opening form,
and signed by me as well as in the documentary evidence provided by me or if any certification becomes incorrect.
4. I also agree that our failure to disclose any material fact known to me, now or in future, may invalidate my application and Union Bank of India would be within its right to
put restrictions in the operations of my account or take appropriate action permissible under the Indian regulations for the purpose or take any other action as may deemed
appropriate if the deficiency is not updated/rectified by me within the stipulated period.
5. I agree to furnish any particulars/information that is called upon me by Union Bank of India on account of any change in law either in India or abroad in the subject matter
herein.
6. In the event there is any tax demand (including interest (if any)) raised due to non-disclosure/inaccurate disclosure of information/document on my/our part, I undertake to
pay the demand forthwith and provide the Bank with all information/documents that may be necessary for any proceedings before GOI/RBI/Income-tax Authorities.
7. I permit/authorize the Bank to collect, store, communicate and process information relating to the Account and all transactions therein, by the Bank and any of its affiliates
wherever situated including sharing, transfer and disclosure between them and to the authorities in and/or outside India of any confidential information for compliance with
any law or regulation whether domestic or foreign.

I confirm having received , read and understood the accounts rules and hereby agree to be bound by the terms and conditions outlined in these rules which govern the
account(s) which I am opening with Union Bank of India and amendments there to made from time to time will be binding on me/us when displayed by the bank on its notice
board or on its website and those relating to various services offered by the bank including but not limited to International debit card/ Internet banking/ SMS banking /Mobile
banking / Tele - banking and other facilities listed in this form . I am aware that the usage of these facilities is governed by the terms and conditions which are displayed on
https://www.unionbankonline.co.in , the site maintained by Union Bank of India and I have reviewed the contents of the same. I understand that the bank may at its absolute
discretion discontinue any of the services completely or partially without any notice to me. I agree that the bank may debit my account for service charges as applicable from
time to time. I declare that the transactions in the account will be made from legitimate sources only the account will not be used for any purpose contrary to law . I declare
that the information furnished above is true and correct to the best of my knowledge.

Account Number

Name of Applicant Arghyadeep Panda

Paste your passport

Branch SHYAM BAZAR - KOLKATA
size photograph and
sign across the
Mode of Operation of Account Single photograph and also in
the box provided
below

Date

Place

For Bank Use Only

9. CUSTOMER DUE DILIGENCE:

Income tax paid during the last two years < Rs. 10,000 Rs. 10,000 - 50,000 Rs. 50,000 - 1 Lac > Rs. 1 Lac

Comments:

PAN Verification from www.incometaxindia.gov.in Nomination Form Received

Applicant's name checked with Suspicious entities list KYC Documents verified with originals

The applicant is KYC compliant Y N Politically Exposed Y N

No. of enclosures: ____ I _____________________(Name of Branch Head/Operations Head),

I hereby declare that this account opening form is complete in all respects Employee No.: _________hereby authorized/permitted to open the account.
and relevant documents have been obtained, verified with originals and P.A. No.:______________
signature is obtained in physical presence of the applicant.
Name: ___________________________
Emp. No. :___________________ Date : ________________ Signature:______________
Date : ________________ Signature:______________

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 Reference No. 23071116185630173833

NOMINATION (NOMINATION FORM DA-1):

Nomination under sec. 45 ZA of the Banking Regulation Act. 1949 and rule 2(1) of the Banking Companies (Nomination) Rules, 1985 in respect of bank deposits.

I nominate the following person to whom in the event of my death the amount in the above account, may be returned by Union Bank of India SHYAM
BAZAR - KOLKATA Branch.

Nature of Deposit Saving Bank Account No.

Name of nominee
Title Full Name
Susmita Panda

Relationship with depositor MOTHER Age

Whether name of the nominee to be printed on Pass Book /Statement of Account/Deposit Receipt Y N

Address
5H, Bidhan Nagar Road, 1st floor

Near Rayan's Muscle Unit

City/District KOLKATA State WEST BENGAL Country INDIA

Pin 700067 Phone No. Mobile No.

E-mail ID

Date of Birth in case of minor @

@ As the nominee is minor on this date I/We appoint
Title Full Name

to recieve the amount of deposit on behalf of nominee in the event of my/our minor's death during the minority of the nominee.
Insurance (Death due to accident)
Nomination for Primary Debit Card
Name Relation Date of Birth
DD

Nomination for Add-on Debit Card

Name Relation Date of Birth
DD

*Signature / thumb Impression of

Depositor

Name of Primary Depositor

Name of Witness/es
Name & Address of Witness 1 Name & Address of Witness 2

Date

Place Signature of Witness1 Signature of Witness2

*Thumb impression(s) shall be attested by two Witnesses

Acknowledgement for Nomination

Recieved on ______________ nomination form DA-1 for making nomination from Arghyadeep Panda in respect of saving bank account.

Deposit Account No. For Union Bank of India

Nomination Registration No.

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Date DD

Authorised Signatory

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