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11A.'l'C A Ann uurc

PA.RT-A 1JSX !!Ff!) 1961 !U!( 28ts8A -g) 0011n ffl?JI9M wRIR<ttt
Addi tiona l man dato ry deta ils requ ired unde
#rnr1 ~
r section 285BA of IT Act 1961
ur1'f len"f Place of Birth
W'f 1'IT irn Coun try of Birth
~ Natio nality
ftfm 'lflT ';fT'f Fathe rs name :
'lftt/lfl"ft im 'lfflr ( ~ ~ t ~) Name of Spou,c (If rnorrled) : amm -.r'ft4J Alldhar Ho. (If IIVllllable) :
1"11 ~ ur;q 1'IT ~tr /~~ / -rrrrft?frnT/iIT
11 your Coun try of Blrth /Natl onalt ty/Ta

11ft ~. ~ ~.:.,i~d
T f.fltro ~€f'R 'lmr t ~~ ~ 3(r,{ t?
x Resid ency othe r than lndla ?( Please
( ✓~)
mark ✓ ) I I '(ES tlO

GfMtt>ifl "· If Yes, Plea se prov ide the

belo w men tione d Info rmat ion:
~ ~~ ~ '{) 31~ 'hr
llJT . ~ ! "ti) lTTJ -q,,:i~n ~ 1{l'lf\ tm
Ift hc indiv idual is tax resid ent in more than one '$ ~ ~ ~
count ry then this infon natio n may be repea ted
1'1. ~( ~~~~~flf
for all such count ries
?fJ'< ~~1 ' { , ~ f ' { ~ l!ST ~ '
1'J'{ ~ ~ ~ ~ ~
S. No Date of Docu ment colle cted Coun try of Resid ency for Tax Tax Ident ificat ion
.. TIN issuin g coun try
purpo ses Num ber (TIN)

~ffil / ~ ll'>T lfflT lt; ~ ~I ll'>T -IJll

Nam e of the Coun try as oer Resid cntia l/Cor resno
~ t@T ,t ~ , m ~ .:rrq
ndenc e addre ss Nam e of the Coun trv as ner Perm ane nt addre
ss

PAR T-B . ~qf<l'<lcp~ ct;~ tJ)ccp T <FATCA> ~ ~ ft-cnt

m m mm ~~
Wll1 7R-~ -\'l qcl1tlo11
FATC A & Othe r Repo rtabl e Accounts Rela
ted Cert ifica tion- cum -Und ertak ing for Indiv
idua ls
,. .,__ _ _ ................ · IDTTfilm 11>""ffll { fa; ft='t ·•nm ,IB!'iR / "11~ =er <JR 1.it<l ( ~) , ~ ~ ~ lr'!m ~ ~u
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mlfll ~ ~~ ~ ~
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q~znh , 1«1 ~ ITT<! ,mnmw/ ~ <mn\ 1f\1 ~
mT<I mm m -,t; T-,q ·i1 ~ / ~ <11r-1 ~ = ~-
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4.
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\l ·•r&'<'T'],0 l i'f\Ul <ITT lfil,c <V-A Ti 1'R 3ffl"I><'! m ~ "R1
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5. tl •rmr •l 31er,rr fll,l'lr i i <1;r'l•1 ·lf fllHfl ,fl qRmf' f "l~ 'l'<'r,,1
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o. lJ~ •r~rn, -q:q,rr ,r,, Wffc-1 'I ~-..}/ /vlR<liR'I i;r.::1-1 wv'I 'H <Wm\
.rmr~ f qi( 3r2iut lfilfc-1 ""'1 <fi q~rflW rfiq <m{
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fl ,r, ~ rC/ l!i)-~ wfl arrlf~l,cp uWr<ITT~ / ~ ~<F <m ~ <IRA <f>l cTt:R ~
7. 11 <ilf<t ~) ~ ( f vlf"'f71;rt) vPlT ffi ,,f'!f!fVr ffi c,rci U-Fi!TTTT <ITT"'
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t
ft-?flli./1 ~ ,ifim m 1111 r1rfil"1ITT~lft
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l:ll ~~ ~ 31:!ql<'A t-g f<ITT~ -.\'\ •
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rlrfwilir, WcITrf 1/mrT t,
3/j'rff-t / ~ ~~i'I 11 <; 1"'1 ~ <f.l
1. /_ _ _ _ _ _ _ _ _ _.certify that I have
decla red my statu s as per the appli cable FATC
of Ind la (GOl) I Centr al Board of Direc t Taxes A/CRS rules tn India as notifi ed by Gove rnmen t
CBDT) Reserve Bank of India (RBl)/ln this regar
2. I certify that the Infor matio n starte d in the accou d.
my knowledge and belie f true, corre ct and comp nt openi ng form and the suppo rting docum entar y evide nce provided by me ts, to the best
lete and that I have not withh eld any mate rial of
asses smen t/ categ oriza tion of the accou nt at
a US Repo rtable accou nt/ Other Repo rtable accou infor matio n/ docu ment , that may affec t the
3. I unde rtake the respo nsibil ity to decla re ,discl nt or other wise.
the accou nt openi ng form, and signe d by me asose and recen tly withi n 30 days any chang es that may take place in the inform ation provi
well as in the docum entar y evide nce provi ded ded
I also agree that our failur e to disclo se any by me or if any certif icatio n becom es incor rect.In
India would be withi n Its right to put restri ction mate rial fact know n to me, now or In futur e, may Inval idate my appli cation and
s In the opera tions of my accou or take Union
regul ation s for the purpo se or take any othe r
action as may deem ed appro priate nt appro priate action perm issibl e under thebank of
lndlan
stipu lated perio d. If the defic iency fs not upda ted/re ctifie d by me within e th
5. I a11ree to furnish any partic ular/ Infor matio n
that fs called upon me by Union Bank of lndla
abroa d In the ,ubje ct matte r herei n . on accou nt of any chanfle In law eithe r In 1n di a or
6. In the event there Is any tax dema nd (1ncludln11 e disclosure of fnform atfon /docu ment
on my/o ur part, I under take to pay the dema nd lntare st (If any) raised due to non • hdfs~tt:,1
proco edlngs befor • GOI /RBI/ lncorno•ta>< Authoforthw ith ond provide the Bank wt 1 n f:,,~!~r
0c,;;'~~~uments that may be neces sary for any
I crrnlt / autho rl,o \he Bank to colle rtt te s.
7. t~u Sank and any of Its affilia tes where ct, 1tore ,cornm~mtcalo and process lnform~tlon
ve r s1Ulu relati ng to th e Account and all transa ctions therei
ouuld e \ndla of any confi dentia l lnformal1on fo te d lncludln11 , shart na, transf er and disclosure betwe en them and to the authorities In and/on, by
r compliance with any law or reauta tlon wheth er r
dome stic or foreign ...

Oate :
Plac.• :
( SI gnatu r fl Of the custo mer with name )
 ,&oow, ~(l(/f,1
Account.Type:
KY( ~ tL 1··1 r , 1 1;r I c1.~r:r
' '

,1

.D Norffle1 ·O SIMpttflN{for &ow ltsk customers) 0 Small

Maict.n Nlme(tf any) : .

~ NIIM(w·~ , :

nu. , ' A-It ~

cu.n u
Alother's·Name-·:
1 1 I:1 11 1 u ,1 ii"U 11.V'r - i:.1:·1-l:~ti r1,; u
TftJe ,-, , .f'lnl ,-_
CIITJL 1 11111
Residential Statui : .· · .

· Ott~,ldent~ . .·..□ Non R~tdent Indian f.JForeign ~at'ional 0Persorf 0f·hlrlt.,n"Orfgln

~ '~~1,,~r"ilIMMdilort only In- .,, P...,..,<t, Drivllll l ~ ) : -

. , , . I ,

D~•-

. Datt t#..,af .ll1U1~':i°f ~ontyklms. otPU!.pGrt I Drtvma Lleenm);

C.I:Jl-1.J[ l I I .
 ~~~· t!il
.,,,,ftq; .flc<JQ •ot Yffi #JTI CITIZENS INTEGRITY PLEDGE
·mr fihcfra ~ ~ pm- ~r ~ 3flfltct;, ~fct«I ; tTm t1IAlf:;lcfi ~~ li"<!itji<
.~ ~
iffllT ~. ~ ~~ ~ ~ ~tsclill< cf1T 3r'{c-fif *
~ ~ Tilft ttcifflrt qffl
~ ffiif,1{, e11,1ft4,1 ntfr ~ 2h ~ Qqi mtl ~ cfil ffl ~ ~ Jncnlfc@T t.
·ml Alitiil ~ ~ Si~ct, i11,,ftq; ~ ~ ~ ~ cftfr ~ ~ ~ Pil-14,fl
cl1U fl~f.)-01 .\; . ~ '11.-icfi i1rrW ~ c\l fiw 4il..til, ~ ~ ~ li&ciitl< ~
~ ~ 1" ln"lT ~ m1tcr.
3lcl:,1t ~Rem ~ i ~ :-
• ~ ~ mft ·~ A $111a1~1~ e1m ~ ~ ~~Hi cf;T ~ ~ ;
• ;:rr ffi ftiacf t{m 3fit o1r ·~ fncrc=r ("10'
• ~ mft m
~Jilii"lfl ~ ~ ~ ~ ~
• Ji~~a ~ ifint ~ ;
• ~ ~ 31itj{0I 1t.$lil~c ,lt) ~<sll<h< 3~1~{01 . \ffgct ~ ;
• ll'<:itjl{ ~ ~ 1ft ~ ~ ~ ~ QJ1;41 ~ ~m

I believe that corrupt ion has been one of the major obstacl es to economic,
political and. social progress of our country. I believe that all stakeho lders
such as ·g overnm ent, citizens and the private sector need to work togethe r to
eradicate corruption. ..,.--·.
I realize that every citizen should be vigilant and commi t to highest
standar ds of honesty and integrit y at all times and suppor t the fight against
corrupti on.
1 therefo re, pledge:
1

• To follow probity and rule of law in all walks of life;

• To neither take nor offer bribe;
• To perform all tasks in an honest and transparent manner;
· • To act in public interest;
• To lead by example exhibiting integrity in personal behavior;
• To report any incident of corruption to the approp riate agency.

if f4WI # :P1f " " " ~ v,,auw,cfr ( I

f ltffr
I would like to take tho above pledge volunta rlly : Ji/Yes D .q1/No D

=~IP I I I I I I I I I I I
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