2-26 (b)

STATEMENT OF ASSETS AND LIABILITES FOR INDIVIDUALS

(For credit limit o R!" #$"$$ l%&'! ( %bo)e)
From
*erm%+e+t Addre!!
*re!e+t Addre!!
Rel%tio+!'i, -it' t'e %,,lic%+t . borro-er
To
T'e Br%+c' M%+%/er
VI0A1A BAN23 44444
I 'ereb5 decl%re %+d co+irm t'%t t'e ,o!itio+ o m5 %!!et3 li%bilitie! %+d i+come
%! o+ 44444 i! %! belo-" I+ !6,,ort t'ereo I %m %l!o !6bmitti+/ 'ere-it'
certiied tr6e co,5 o m5 l%te!t %)%il%ble -e%lt' t%7 %+d i+come t%7 %!!e!!me+t
order! . co,5 o 8T ( IT ret6r+! iled %lo+/ -it' doc6me+t%r5 ,roo or '%)i+/
,%id t%7 d6e!
A" ASSETS9
# LANDED *RO*ERT:ES
%) De!cri,tio+ o t'e ,ro,ert5 %+d or -'%t
,6r,o!e it i! bei+/ c6rre+tl5 6!ed
(V%c%+t L%+d .A/ric6lt6r%l l%+d .
B6!i+e!! ,remi!e!. Re!ide+ti%l
Accommod%tio+ etc")
b) Loc%tio+ ( Addre!! (8it' !6r)e5 No".
*%tt% No".S6b-di)i!io+ No" etc"3)
c) Are% E7te+t
d) ;o- %c<6ired %+d -'e+
e) 8'et'er !el occ6,ied.)%c%+t.le%!ed
) I le%!ed.re+ted o6t to -'om %+d till
-'%t d%te
/) I %lre%d5 mort/%/ed 6ll det%il!
') *re!e+t M%r&et V%l6e
L%+d R!"
B6ildi+/ R!"
2 Mo)%ble ,ro,ertie! (Item! o ,erm%+e+t +%t6re -it' )%l6e o R!" #$3$$$.-
%+d %bo)e %! o+ d%te)
(%) M%c'i+er5 . E<6i,me+t . Motor Ve'icle
De!cri,tio+ o t'e
item
D%te o
*6rc'%!e
I+)oice
)%l6e
(R!)
*re!e+t
)%l6e
(R!)
I e+c6mbered to
-'om %+d to
-'%t e7te+t
(b) 0e-eller5
Net
-ei/'t
(=m!)
*re!e+t r%te
(R!)
Tot%l )%l6e (R!) I e+c6mbered to -'om %+d
to -'%t e7te+t
(c) B%+& %+d ot'er de,o!it!
8it'
-'om
de,o!ited
N%t6re o
de,o!it (RD .
FD .
>6m6l%ti)e)
Amo6+t o
de,o!it
(R!)
D6e
D%te
I e+c6mbered i+ -'%t
-%5 %+d to -'%t e7te+t
(d) I+)e!tme+t i+ !'%re.ot'er!
#" I+)e!tme+t i+ !'%re!.debe+t6re!.NS>.NSS etc"3
N%me o t'e
com,%+5
No" o
!'%re! .
debe+t6re!
'eld
F%ce
V%l6e
(R!)
M%r&et
V%l6e
(R!)
I e+c6mbered +%t6re
%+d e7te+t
2" I+)e!tme+t i+ ot'er irm!.com,%+ie!
N%me o t'e
>om,%+5
I i+tere!ted i+ t'e
com,%+5 +%t6re o
i+tere!t
Amo6+t
i+)e!ted
ori/i+%ll5
Amo6+t ,re!e+tl5 d6e
%+d recei)%ble
?" Lie I+!6r%+ce *olicie!
*olic5
N6mber (
d%te
S6m
%!!6red
(R!)
D%te o
m%t6rit5
8'et'er
,remi6m i!
,%id 6, to
d%te
Tot%l
,remi6m
,%id !o %r
(R!)
I
e+c6mbered
+%t6re %+d
e7te+t
*%/e 2 o @
(e) Ot'er A!!et! (8it' Det%il!) >'it 6+d3 26ri Ad)%+ce i %+5 ,%id
B" LIABILITIES9
Sl No Det%il! Amo6+t (R!)
# Borro-i+/! rom ViA%5% B%+&3 444444 Br%+c'
2 Borro-i+/! rom ot'er B%+&!.I+!tit6tio+!3 -it' det%il!
? Li%bilitie! %! /6%r%+tor o+ -'o!e be'%l.to -'ic'
I+!tit6tio+ (>o+ti+/e+t Li%bilitie!)
@ M%r&et borro-i+/.S6+dr5 >reditor!
B St%t6tor5 Li%bilit5 (I+come t%7.8e%lt' t%7)
Summary/Position
FOR BRANCH USE ONLY
Amo6+t i+ $$$C!
Sl
No
Det%il!
V%l6e %!
%!!e!!ed b5
,%rt5
V%l6e %!
%!!e!!ed
b5 t'e
Br%+c'
M%+%/er
(%) ASSET
V%l6e o L%+ded ,ro,ert5
V%l6e o M%c'i+er5 ( E<6i,me+t!
V%l6e o Motor Ve'icle!
V%l6e o =old ( Sil)er
Amo6+t o B%+& De,o!it!
I+)e!tme+t i+ !'%re! ( debe+t6re!
I+)e!tme+t i+ ot'er irm!.com,%+ie!
*remi6m *%id o+ Lie *olicie!
Ot'er A!!et!
Tot%l
*%/e ? o @
(b) LIABILITIES
Amo6+t d6e to ViA%5% B%+&
Amo6+t d6e to ot'er b%+&! . i+!tit6tio+!
M%r&et borro-i+/!
St%t6tor5 li%bilitie!
Tot%l
(c) NET MEANS D(%) E (b)F
(d) IN>OME
Re+t%l I+come
I+tere!t I+come
A/ric6lt6r%l I+come
B6!i+e!! I+come
Ot'er i+come3 i %+5
Tot%l
DE>LARATION
I 'ereb5 decl%re t'%t t'e %bo)e ,%rtic6l%r! %re tr6e %+d correct %+d I '%)e i+ m5
,o!!e!!io+3 +ece!!%r5 doc6me+t%r5 e)ide+ce i+ !6,,ort t'ereo3 -'ic' !'%ll be
,rod6ced to 5o6 or )eriic%tio+ %! %+d -'e+ c%lled or 5o6" I %l!o decl%re t'%t
t'e %!!et! li!ted %bo)e %re 6ll5 o-+ed b5 me %+d t'e5 %re +ot %lie+%ted .
e+c6mbered e7ce,t to t'e e7te+t %! !t%ted t'ere %/%i+!t" I 'ereb5 6+dert%&e
+ot to e+c6mber . %lie+%te t'e !%id ,ro,ertie! . !et! -it'o6t i+tim%tio+ to 5o6
till %ll m5 obli/%tio+! to t'e b%+& %! % borro-er . /6%r%+tor %re 6ll5 di!c'%r/ed"
Si/+%t6re
*l%ce9
D%te9
>ERTIFI>ATE B1 MANA=ER
I3 4444 t'e Br%+c' M%+%/er3 44444 Br%+c' 'ereb5 certi5 t'%t3 I '%)e )eriied
t'e i+orm%tio+ 6r+i!'ed %bo)e -it' rel%ti)e record! %+d t'e %!!e!!me+t m%de
%bo)e i! tr6e %+d %ir 'e be!t o m5 &+o-led/e %+d belie"
Si/+%t6re o t'e Br%+c' M%+%/er
D%te9
*%/e @ o @