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Divyangjan Form

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29 views

Divyangjan Form

Uploaded by

jitbhoumick3355
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Declaration by Visually and/ or Audibly Challenged Divyangjan for availing of

Aadhaar Enabled Payment System “AEPS” Service (“Declaration”)

Date:____________

To,

RBL Bank Ltd.

I, _________________________________________________________________________, (name of Aadhaar holder – “Aadhaar Holder/Declarant”)


wish to avail the below- mentioned Aadhaar Enabled Payment System (AEPS) service from RBL Bank.

Cash withdraw of Rs ___________

Balance Enquiry

Mini-Statement

from my Bank account held with ______________________________________________ (name of the Aadhar Holders Bank). I hereby agree to submit
my Aadhaar number / VID and my biometric information to RBL Bank “RBL Bank” Customer Service Point (“CSP”) for availing the selected above-
mentioned service.

I hereby state that –

 I understand and agree to abide by the terms and conditions of the AEPS Service as conveyed by the CSP on behalf of RBL Bank.
 I have no objection to RBL Bank for authenticating my details vide Aadhaar based authentication system and hereby consent to the usage of
my Aadhaar number, Biometric and/or One Time Pin (OTP) for the purposes of availing of the AEPS services from RBL Bank.
 I understand that my Aadhaar details shall only be used in accordance with this Declaration and applicable laws and for no other purposes
by RBL Bank.
 I understand that RBL Bank shall ensure security and confidentiality of my personal identity data provided for the purpose of Aadhaar based
authentication as required under applicable laws.
 I hereby confirm that I am aware of the alternatives to submission of identity information.
 I hereby confirm that the witness named herein has executed this Declaration and its contents in my presence and knowledge along with the
CSP of RBL Bank.

Signature(s)/thumb impression(s) as given hereinbelow of the Aadhaar holder:

Witness:

I hereby declare that this Declaration is executed in my presence and herby confirm that the contents of this Declaration is true.

Signed by Mr. / Ms. ____________________________________________________________________ (name of the witness in whose presence the
declaration is explained by the CSP and signed by the Aadhaar holder)

Place: ______________________ Mobile: _____________________ Relation to the Aadhaar holder:_____________________________________

Signature(s)/thumb impression(s) of witness:

CSP Declaration:

I declare that I have duly explained the terms and conditions of the AEPS service to the Aadhaar holder and the witness for obtaining the consent of
the Aadhaar Holder for the purpose of availing of AEPS services.

I have also read this Declaration to the Aadhaar Holder in presence of the witness. Further, I declare I have not taken any charges for the AEPS
service from the Aadhaar holder.

Date: ______________________ Place : ______________________ Transaction Number (RRN):________________________________________

Stamp and Signature of CSP:

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