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

                                                                                    Serial No............................

APPLICATION FOR OPENING OF AN ACCOUNT UNDER
SENIOR CITIZENS SAVINGS SCHEME, 2004

TO
       The Postmaster / Incharge
       .
...............................................(name of the Deposit office)

       ........................................

.      .......................................
 

Paste here a copy of
 recent  photograph

(Joint Photograph of both the Depositor & Spouse in case of a joint account)

   * Name of Agent (in case of the account introduced through agent) ................................................................
Agency Code No. ......................................................Dated ..................................valid upto .......................


PAN No. (of applicant) .....................................

Sir,    
  1.    I .................................................................. son/daughter/wife of .....................................................     a  permanent resident of ........................................................................................................................................  aged ................................  years. hereby apply for opening of an account under the Senior Citizens Savings 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 Rs. ...................... (Rupees. .......................................................................) in cash / cheque / demand draft the particulars of which are filled in the enclosed "pay-in-slip" (Form-D), towards deposit in the account.

2.     I/We hereby declare that,
(i)     I/We have clearly understood the Senior Citizens Savings Scheme Rules, 2004 governing the accounts under
         the said scheme as amended from time to time (hereinafter referred to as the said rules).
(ii)     I/We shall abide by the said rules in letter and spirit.
(iii)    the details of other accounts opened earlier by me/us under the scheme are as under
 

Sl.
No.
Name of depositor(s) & Type of account (individual / joint) Name and Address of the Deposit office Account No. with date of opening Amount of Deposit
1
2        
3
         


(iv)    I/We shall adhere to the ceiling on deposits, taking the deposits in all the accounts opened by me/us together  as specified in rule 4 and amended from time to time. In case, at any time any excess deposit is found such excess deposit will be refunded to me/us after recovery of excess interest under sub-rule (8) of rule 7.

 

 

3.     I nominate the following  person / persons, mentioned below, to whom, to the exclusion of all other persons, in   the  event  of  my  death  the  amount  standing   to  my   credit   in   the   account    would   be   payable in accordance with the provisions contained in rule 6.

 
Sl.
No.
Name(s) of nominee(s) along
 with relationship with the depositor
Permanent Address Date(s) of birth
 nominee(s) in case of a minor/age in other case(s) 
Share of the nominee(s) in the amount payable
1        
2        
3        
 
Photograph(s) of the nominee(s) Signature / thump 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 my death during the minority of the nominee(s). 
                                                                                                    

                                                                                                            Signature /Thumb impression of the depositor
Witnesses (Signature, Name and Address):
 
1. ............................................................ 

2.............................................................                Date ........................... At (Place)........................
My /our specimen signatures (thumb impression) are as below:
(1) First Depositor:-
 
1.  

2.

 

3.

 

(ii)

    Joint depositor        

1.

 

2.

 

3.

 

#

 Witness ............................

#

Witness ............................

#

Witness ............................
             Countersigned Postmaster /Incharge)
             Date .....................& Office Seal
            Countersigned Postmaster /Incharge)
            Date .....................& Office Seal

             Countersigned Postmaster /Incharge
             Date .....................& Office Seal


 

4.

I also declare that the information provided by me/us *in the application herein above, is true to the best of my/our knowledge and belief and in case, at any time, any of the information and /or declaration is found false, no interest on the deposits shall be payable to me/us*, the deposit office shall close the account(s) and refund the deposits after recovery of the interest, if any, already paid on the deposits.

Yours faithfully


 
 Date:............................                                                                                              (Signature of the Applicant)

Place:...........................                                                                                                   (Present Postal Address)
 
Enclosures:
1 Age Proof.
2 Copy of receipted application form for allotment of PAN, if PAN is not allotted.
3 Pay-in-slip (Form-D) duly filled in along with amount of deposit.
4 Certificate from the employer as specified in sub-clause (ii) of clause (d) of rule 2.
* Score out whichever is not applicable
**(1) The applicant(s) who are not assessed to income tax, may furnish a self declaration, that their income from all sources (including the interest income from the account to be opened vide this application) does not cross the exemption limit and the applicant is not required  to obtain PAN under Income Tax Act, 1961, as amended from time to time.

(2) All other applicants shall mention the PAN  No. compulsorily and in case they have not so far 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 enclosed as age proof.  Birth certificate issued by the Municipal authority / Gram Panchayat /District office of the Registrar of Births and Deaths ; Voter Identity Card issued by the Election Commission of India ;  PAN Card;  Passport; Ration Card; Date of birth certificate from the school last attended by the applicant or any other recognised educational institution or Driving Licence issued by the the local licensing authority
(2) Originals of the documents attached, should also be produced simultaneously for verification and return immediately.

FOR      THE     USE      OF      DEPOSIT      OFFICE

         The Account has been opened on .......................................... with Rs..........................................  (Rupees ......................................................................) under the Senior Citizens Savings Scheme, 2004.
Account No...................................... Ledger Folio No.............................................

Agent's name, agency code number, date and validity have been entered in the ledger folio as well as Pass book         ( in case of account introduced through agent).
 
Pass Book No..................................has been issued

Date..................................

Signature  of the Incharge of Deposit Office
(along with name and designation stamp)