F.N.

135

Bank of Baroda
(HEAD OFFICE, MANDVI, BARODA)
PARTICULATS TO BE SUPPLIED BY THE APPLICANT/GUARANTOR FOR ADVANCE
I give below the particulars of my self, my family and Assets & Liabilities as at
1. Name in Full : Anil Maddheshiya 2. Age : 30 years
Father’s/Husband’s Name : Late Jai Prakash 4 Date of Birth : 12/10/1991
TH
5. Education Qualification : 9 PASS
6. Residential Address :
PERMANENT PRESENT
SO JAI PRAKSH
WARD NO 12 PIPRA
NAGAR PANCHAYAT PIPRAICH
GORAKHPUR PIN-273152

7. Telephone Numbers : Office/Shop ___________________________________ Residence __________________

8. Occupation/line of business : Business (Egg and Hatchery related )
(A) If in service : _________________________________________________
Name of employer and : _________________________________________________
Address : _________________________________________________
Designation : _________________________________________________
(B) If in business/Profession :
i) Name/s of the Firm/Company : Anil Agency (Prop-Anil Maddheshiya)
Line/s of activities : Egg selling (Current ) and Hatchery (Proposed)
iii) Since when established : 2019
iv) In which capacity he/she is : Self
representing
9. Annual Income : Rs. 313341/=
10. PAN (if Income Tax Assessee) : EEEPK3271K
11. DETAILS OF ASSETS
11.1 Details of immovable properties (Held in own name/joint name)
(A) Nature of properties (Please tick whichever applicable)
i) Plot of land
ii) Agricultural land
iii) House/Godowns : Residential Plot
iv) Others
(B) Location: Ward No 12 Nagar Panchayat Pipraich Survey/House No. _________________________
Area/Locality : Pipraich
Village/Town : ________________________________________ District: Gorakhpur
(C) Property in whose name? : Munni Devi
(D) Cost (at the time of purchase) : Rs. : ____________________________________
(E) Present estimated market value of the property/ies : Rs. : 2379000/=
(F) Whether encumbered/un-encumbered/ : Unencumbered
Partially encumbered/un-encumbered, give details viz with whom,
Consideration and major terms & conditions)
11.2 DETAILS OF MOVEABLE PROPERTIES IN MY NAME :
(A) Life Insurance Policies :
Company & Policy Date of Insurance Sum Assured Annual Premium Premium paid Surrender
Br. Name No. of Policy & Period (Rs.) (in Rs.) upto what period Value
1 2 3 4 5 6 7

(B) Share/Debentures etc. :

Name of the Total No. of shares Certificate No. A/c Total Amount Rs. Whether Fully Current Market
Company held No. (Face Value) Paid (Yes/No) Value Rs.
(C) Saving Bank A/c. No. : Date of opening Fvg. Name of Bank/ Balance outstanding
Branch
FDR/RD YSJY
A/c No. Date Fvg. Amount Name of Bank/ Due Maturity
Rs. Branch Date Value Rs.

(D) Investment in Government Securities Like Bond/NSC etc.

Bond/Certificate Date of Issuing Office/Post Office Add. Amount Due Maturity
Purchase (Including Mutual Funds) Rs. Date Value Rs.

11.3 Details of vehicle/s owned by me: Reg. No. UP 53 AR 5504 Type of Vehicle :Honda Activa Present Market Value
Rs. 30000/-
11.4 Capital invested in business Name of
Firm/company (As on latest balance sheet date : )651892/-
11.5 Full details of other investments if any, : ______________________________________________________
(i.e, jwellery, investment in other firm, etc.)
11.6 Total of all assets (11.1 to 11.5) : Rs 651892/=+30000/=681892/-
12. DETAILS OF LOANS IN INDIVIDUAL NAME/FIRM’S NAME/COMPANY’S NAME
a) Name/s of the Bank/other Institution and its branch : ________________________________________
b) Purpose and amount of loan availed : ________________________________________
c) Security & repayment schedule/Rate of interest : ________________________________________
d) Present balance outstanding : ________________________________________
e) Liabilities other than to Bank and Financial Institution/s : ________________________________________
13. Other Details:
Details of personal guarantee
given for any person/firm. If so, furnish details (i.e. Name of
the Bank/Institution, on whose behalf, amount of guarantee,
present status of A/c. etc.)
14. (A) Particulars of Legal Heirs :
Sr. No. Name Relationship Age Present Address Occupation
1 2 3 4 5
6
Aanchal Wife 28 Ward 12 Pipraich Housewife
Ananya Daughter 3 Months Ward 12 Pipraich

(B) Nomination Particulars :

Sr. No. Description of Asset Bank/ Account/ Amount (at
(Bank Dep., Co. Dep., Organisation Certificate No. Present/ at
Terminal Benefits etc.) maturity)
1 2 3 4 5

In support of my above declaration, I enclose :

1. Balance sheet, Profit & Loss Account, Trading Account, Capital Account (Audited/unaudited)
2. Copy of employment certificate with details of salary drawn.
3. Copies of agreement/revenue records/society certificates in respect of land/building/flat owned by me.
15. I declare that :
I am/ I am not (tick as applicable) a Director in ___________________/any Bank
There is no litigation against me or the name of the partners/proprietor/Director of the firm/ Co. is not on the
caution list of RBI/ECGS. The proprietor/partners/Directors of the firm/ Co. is/are not the Directors in any Co-
operative Bank
I also declare the above information is complete, true and correct.
Encls. :
Place : Pipraich Date :17/02/2020 Signature