FORM-A

(See clause (d) of rule 2 and sub rule (1) of rule 3)

rPLICATION FOR OPENING OF AN ACCOUNT UNDER
SENIOR CITIZENS SAVINGS SCHEME, 2004
To,
The Chief / Branch
State Bank of IndiaManager

Sir / Madam,

PAN (Applicant)
1. I ,
resident of Son/Daughter/Wife of a permanent
aged years, hereby apply for
Opening or an account under the Senior Citizens Savinns Scheme, 2004,
(hereinafter referred to as
the said scheme), in My Name /
Jointly in My Name and My Spouse
(name and address of spouse with age) *and tender herewith
(Rupees Only) in Cash / Cheque / Demand Draft, the
particulars of which are filled in the enclosed 'pav-in-slip'(Form-D), to wards deposit in
the account.
2. I/we* hereby declare that,
() I/we* have clearly understood the Senior
Citizens Savings Scheme Rules, 2004 governing the
accounts under the said scheme, as amended from time to
said rules); time(hereinafter referred to as the
(ii) I/we* shall abide by the said rules in
letter and spirit;
(iii) The details of other accounts opened earlier by mne/us* under the
said scheme, are as under:

SI. Name of Depositor(s) & Type Name and

No. Address of the Account No. with Amount of
of Account (Individual/ Joint) date of opening
Deposit office Deposit
1.

2.

3.

Note: In case of More SCSS A/C please Enclose a detail list of the all.

(iv)I/we* shall adhere to the ceiling on depoSits, taking the deposits in all the accounts onened hy
Me us* together, as specified in rule 4 and amended rrom time to
ny vcess denosit is found, such excess deposit will be refunded to time. In case, at any time
me / us* after recovery of
excess interest under sub-rule (8) of rule 7.

3. Inominate the following person / persons, mentioned beloW, to whom, to the exclusion of all other
ho event of my death the amount standing to my
credit in the acoount wOuld be
payable in acCordance with the provisions Contained in rule 6:

SBLFORAIS AY 45?78%
 TABLE

SI. Name(s) of the Date(s) of birth of Share of the

No. nominee(s) along with nominee(s) in case nominee(s)
relationship with the Permanent Address of a minor/ age in in amount

1.
depositor other case(s) payable.

2.

3.

Photograph(s) of the Nominee(s) Signature/Thumb impression of the

Nominee(s)

3. (a) As the Nominee(s) at Serial No. (s) above is/are minor(s), I appoint Shri / Smt. / Kumari
[Name(s) with Permanent
Address(es) of the person(s) in respect of each minor nominee] to receive the sum due
under the
said account in the event of mny death during the
minority of the nominee(s).

Signature/Thumb impression of the Depositor(s)

Witnesses(Signature, name and address):
1) 2)

My/our* Specimen signatures (Thumb impression), are as below:

(i) First Depositor:

1. 2. 3

(ii) *Joint Depositor:

1, 2. 3.

#Witness #Witness
#Witness

(Countersigned by Serv. Manager) (Countersigned by Serv. Manager)

Date: /20
(Countersigned by Serv. Manager)
Date: J/20_ Date: /20

SBEORNtS AY sD8
4. I also declare
the best of that the information
and provided
by me / us* in the application hereinabove, is true to
declaration ismy/our
found knowledge belief and in case, at any time, any of the information and/or
false, no
Snall dOSe tne account(s) and interest on
on the deposits. refund the the deposits shall be payable to me/us*, the deposit office
denncits after recovery of the interest, if any, already paid
Yours faithfully,

Date V : 2 0
Place (Signature of the Applicant)

Encdosures:
(Present Postal Address)
(i) Age Proof
(0) Copy of receipted application form for allotment of
(ii) Pay-in-Slip (Form-D), PAN, if PAN is not allotted.
duly filled in along with amount of Deposit.
(iV)Certificate from the employer as specified in sub-clause (ii) of dause (d) of rule 2.
: Score out
whichever is not applicable.
: Qne applicant(s) who are not assessed to
income tax, may furnish a self declaration, that
their income from all sources (includina the interest
this application ) does not cross the exemption limit income from the account to be opened vide
and the applicant is not required to obtain
PAN under Income Tax Act, 1961, as
amended from ti me to time.
(2) Al other applicants shall mention the PAN Compulsorily and in case they have not sO Tar
been allotted PAN by the Income Tax Authorities, attested photocopy of the receipted
application form for allotment of PAN should be attached to the application form.
: In case of Thumb
Impression.
NOTE:
(1) Self attested copies of any of the following
documents can be
Birth Certificate issued by the Municipal authority/ Gramenclosed as age proof:
Panchayat / District Office of the
Registrar of Births and Deaths;
Voter Identity Card issued by the Election Commission of India;
PAN Card:
Passport;
Date of birth certificate from the school last attended by the applicant or any
educational institution other recognised
Driving License issued by the lo cal licensing authority.
(2) Originals of the documents attached, should also be produced simultaneously for verification and
return immediately.
*** *** 7**k**k

FOR THE USE OF BRANCH

The ACcount has been opened on /20 with F

(Rupees
Only) under the Senior Citizens Savings Scheme, 2004.
Account No: Pass Book No: has been issued.

Date J20

(Branch /Service Manager)

SBIFORNtS 8Y 4577S%
 FORM-D
(See sub-rule (1) of rule 3 and rule 10)
PAY - IN - SLIP FOR DEPOSITS
UNDER SENIOR CITIZENS SAVINGS sCHEME, 2004
COUNTERFOIL - 1 COUNTERFOIL-2

BANK'S COPY
DEPOSITORS COPY
SBIBRANCH NAME SBI BRANCH NAME :
NAME & ADDRESS OF DEPOSITOR: ADDRESS OF DEPOSITOR:
NAME

FATHER/HUSBAND NAME : FATHER/HUSBAND NAME :

SCSS A/C NO ScSS A/C NO

AMOUNT OF DEPOSIT AMOUNT OF DEPOSIT

CHEQUE/DD REALISATION CHARGE CHEQUE /DD REALISA TION CHARGE

ACCOUNT TRANSFER FEES ACCOUNT TRANSFER FEES

DUPLICATE PASSBOOK FEES DUPLICATE PASSBOOK FEES

OTHER CHARGES IF ANY OTHER CHARGES IF ANY

TOTAL AMOUNT TOTAL AMOUNT

(Rupees_ (Rupees
DETAILS OF CASH DEPOSIT AMOUNT DETAILS OF CASH DEPOSIT AMOUNT

1000 1000 X
XX|x|xX>
500 X 500 X
100 100
50 50
20 20 X
10 10 X
Total By Cash Total By Cash
Cheque /Demand Draft No & Date Cheque / Demand Draft No & Date
&.......... 20....... *.......s....*.......... &.../....J20.........
Bank / Branch on Which Dravwn Bank / Branch on Which Drawn

Depositor's Signature Depositor's Signature

For the Use of Branch For the Use of Branch
Received (Rupees Received (Rupees
Only) as Only) as
detailed herein above. For deposit in SCSS detailed herein above. For deposit in SCSs
A/c No A/c No

Teller /Cashier Service Manager Teller /Cashier Service Manager

NOTE:
1. The cheque/demand draft should be in favour of the
"YOURSELF FOR SCss DEPOSIT" or in favour of the
"Depositor SCSS A/C endorsed in favour of the SBI.
Z. heques / Demand Drafts are subject to realisation of
the proceeds.
NOTE:
1. The cheque/demand draft should be in favour of the
"YOURSELF FOR SCSS DEPOSIT" or in favour of the
"Depositor SCSS A/c" endorsed in favour of the S8I.
2. Cheques/ Demand Drafts are subject to realisation of
the proceeds.

SBI FOSAS 8Y 4577825