PM Street Vendor’s AtmaNirbhar Nidhi(PM SVANidhi)

(Common Loan Application Form)

* Mandatory fields
** Only for SV's from Assam and Meghalaya, not having Aadhaar Number
# Data Fetching From Aadhaar

Application No. PMS092310156964 Name of Preferred Bank/Lender -

#Name of Street Vendor Pratiksha Buch Father/Spouse Name* Deepak buch

#Date Of Birth 04/03/1999 Marital Status* Married

#Mobile Number* 9893515325 #Gender Female

Social Category* OBC

Are you vending in the same State you Are you vending in the same district
belong to?* you belong to?*

PwD (Divyangjan)* Minority*

KYC Details

#R-Token Number* Voter ID Card No.*

240536882023 UIR3148129

Family Details
Name* Relationship With Applicant* Age*
SAKSHAM BUCH Unmarried Son 2
DEEPAK BUCH Husband 31

Proof Of Vending
Vendor ID Card Certificate of Vending No. Letter Of Recommendation (LoR) No.
(Issued by ULB) (Issued by ULB) (To be issued by ULB electronically through PM SVANidhi Portal)
MP/250946/230930/6529044

Address as per e-KYC

#House No. / Locality H No-1078, Ashok ViharAnand Nagar #State MADHYA PRADESH

#Town/Dist Bhopal #Ward/Village Huzur

#Pin Code 462022

Current Address

House No. / Locality* H No-1078, Ashok ViharAnand Nagar State* MADHYA PRADESH

Town/Dist* Bhopal Ward/Village* Huzur

Pin Code* 462022

Vending Activity

Name Of Activity* Home Decor& Handicrafts

Other

Place Of Vending* Fixed Location

Duration Of Vending* 09/2022

Location/Area of Vending

Stationary Vendor ASHOK VIHAR Nearest Landmark BATHRA CUNTRACATION

Mobile Vendor Nearest Landmark

State* MADHYA PRADESH Town/Dist* Bhopal

ULB Name* Bhopal Municipal Corporation

Ward/Village*

Pin Code 462022

Total Monthly Family Income (₹) (Family means husband, wife and unmarried children)

Total Monthly Family Income (₹)* 12000

Bank Account Details

Name Of Bank* Name Of Branch* IFSC Code* Account No*
Union Bank of India ANAND NAGAR - BHOPAL UBIN0540293 402902120004143

Digital Payment

Payment Aggregator UPI ID / VPA Durable QR Code

Existing Loan Outstanding

Bank/Lending Institution Outstanding Amount (in Rs.) Monthly EMI (in Rs.)

Loan Amount Required (₹) Loan Tenure Status

1stTerm Loan Amount 10,000/- 12 Months Active

2nd Term Loan Amount 20,000/- 18 Months

3rd Term Loan Amount 50,000/- 36 Months

Loan Purpose* Working Capital Business Expansion Purchase Of Assets

Declaration and Authorization:

A. I hereby certify that all information furnished by me is true, correct, and complete. I have no borrowing arrangements except as indicated in the
application form. I have not applied to any other lending institution under the PM SVANidhi scheme. The information submitted herein may be exchanged
by you with any agency, you may deem fit. You, your representatives, Lending Institution (LIs) or MoHUA, or any other agency as authorized by you /
MoHUA / LI, may at any time, inspect/ verify my/our assets etc. You may take appropriate safeguards/action for recovery of lending institutions’ dues.

B. I understand that by submitting this application form, I am providing my consent for application for loans in 3 cycles. My maximum loan amount in the
first cycle will be ₹10,000/. On full repayment of the 1st loan, in the 2nd cycle, maximum loan amount will increase to ₹20,000/- and after full repayment
of 2nd loan; in the 3rd cycle, maximum loan amount will increase to ₹50,000/-. For the purpose of 2nd and 3rd loan, my application will be auto generated
after full repayment of previous loan and sent to the lender. I will become eligible for the next cycle of the loan only after full repayment of earlier loan and
submission of digital consent for the subsequent loans.

C. I have no objection to authenticate my Aadhaar number, share the same with other Ministries / Departments under the Government of India or the State
Government for the purpose of extension of benefits under any of their Schemes, carry out e-KYC and accessing my credit history & credit score
from credit bureau by the lenders and their authorized agents. The consent and purpose of collecting Aadhaar has been explained to me in local language.
MoHUA/Lending Institution has informed me that my Aadhaar submitted herewith shall not be used for any purpose other than mentioned above, or as per
requirements of law. I have been informed that this consent and my Aadhaar will be stored along with my account details with MoHUA or their authorised
agent.

D. I have been vending in the urban local body on or before “Vending Since (09/2022) selected by SV”.
E. I hereby declare that the above information is correct / accurate to the best of my knowledge.

Date : 30/09/2023 Signature of Applicant(s)

Place : Bhopal