CBD-23

Rev. - 2006

BANK OF INDIA
Bhubaneswar Branch
BORROWERS/GURANTORS PROFILE

The Branch Manager,

Bank of India
Nabarangpur Branch
NABARANGPUR
I hereby declare that the information provided below by me is true and correct and I undertake that if at any point of time
hereinafter it transpires that any information provided/to be provided by me is found to be incorrect/false, the Bank shall
be at liberty to recall the advance forthwith, irrespective of the contracted terms of the loan I would repay forthwith, the
entire loan outstanding then together with interest/penal/additional interest and other charges. I undertake to provide any
further information as Bank may ask from me time to time. I also undertake to execute necessary documents for
guaranteeing the loan. I further declare insolvency proceedings have been initiated againdt me or pending in any court.
1. Name: (Shri/Smt./Kum)
(Surname)
2.Resident Status:
Resident
3.Fathers Name/Husbands Name
4.Present Address:

City

(Name)

(Middle Name)

Non-Resident Indian

Foreign Resident

5. Permanent Address

City

PIN
PIN
Tele. No.
Tele. No.
Premises : Owned
Premises: Owned
Duration
of Stay:
Duration
Mobile No.
Mobile
No. of Stay:
6. Age & DOB:
7. Nationality:
8.Sex: Male/Female
8.Educational Qualification:
10.Occupation: Service/Business/Retired (Last employment with)
A. If in Service
Address________________________________________________________Tel No._____________________________
Service Since ______________________Post Held ________________________Date of Retirement_________________
B. If in Business: Name of the Company:
Address:

Line of Activity/Experience:
Establish Since:

Position:

11. Annual Income:

No.
13. Identification: (Enclose Copy)

12. PAN

14. Detail of Bank Accounts:

Sl.
No.

Bank Name

Branch Name

Account Type

Account No.

Current Balance

14. Details of Assets:

A. IMMOVABLE PROPERTY
Particulars

Ownership

As on 31.03.2015

Area in
Sq.mtrs

Free Hold
or Lease
Hold

Location / Address

B. MOVABLE PROPERTY
i. Insurance Policies
Name of the Company &
Branch

Last six
mnths avg.

Purchase
Cost
Amount in
Rs.

Present
Value
Amount in
Rs.

Whether
encumbered
(Give details)

(Amount in Rs.)
Policy No.

Date of
Issue

Sum Assured

ii. Shares/Debentures/Mutual Fund etc.

Name of the Company & Branch

No. of
Shares

Surrender
Value

Annual
Premium

Premium paid
upto what
period

(Amount in Rs.)
Certification
No./Account No.
Demat Account No.

Scheme

Whether
fully paid
(Yes/No)

Current
Market
Value

iii. Term Deposits:

(Amount in Rs.)

Term Deposit Receipt

No.

Bank/Branch Name

Type

Amount & date

of receipt

iv. Investment in Govt. Securities like Bonds/PPF/NSC/KVP/IVP etc

Bond/Certificat
e No.

Nature of Secutity

Date of
Purchase

Issuing Office/
Post Office

Maturity
Amount

(Amount in Rs.)
Face Value

v. Vehicles
Type of
Vehicles

Maturity
Date

Due Date

Maturity
Amount

(Amount in Rs.)
Registration
No.

Model

Year of
Make

Cost at the time

of Purchase

vi. Jewellery:
Quantity

Valuation (Approx)*

GOLD
SILVER
OTHERS
(* Attach Valuation Certificate, if available)
15. LIABILITIES:
i. As Borrower
Purpose of Loan

Details of Shridhan, if any

(Amount in Rs.)

Amount of Loan

Security

ii. As Guarantor
Name of the person
whom Guaranteed

Present Value

(Amount in Rs.)

Particulars

Borrowed from

RC Book
Details

Repayment Terms

Outstanding
Balance

(Amount in Rs.)
Name of the
Bank/Financial Institution

Guarantee
Amount

Present status of
account

Outstanding balance

16. Legal Heirs/Family Particulars

Name

Occupation

Relation

Age

Marital Status

Address

17. Any other relevant particulars (If needed then add separate sheet)
In support of any declaration, I enclose:

Place:
Date:
Worth assessed as per market report and the details
provided by the proponent Rs.
(Bank
Official)
Verified the documents (With the original)
by..
________________________
Signature & Code
Date:

________________________________
(Signature of Borrower/Guarantor)
In case of Guarantor, signature verified
(by the Borrower)

________________________
Borrowers Signature