PM Street Vendor’s AtmaNirbhar Nidhi(PM SVANidhi)

(Common Loan Application Form)

Application No. PMS01214162951

Name of Street Vendor* Brajen Hazarika Father/Spouse Name* Rupsing Hazarika

Date of Birth* 2/28/1983 12:00:00 AM Marital Status* Married

Mobile No* 8876995374 Gender* Male

Social Category* General Nativity Rural

PwD (Divyangjan)* Minority*

KYC Details

Aadhaar No* Voter ID Card No.* Driving License No Ration card No. Others(Govt Approved Document)

687823155712 CTH9340403 3329527

Family Details

Name* Relationship with Applicant* Age*

BRAJEN HAZARIKA Husband 37

RUPSING HAZARIKA Father 75

ANU KAKATI Wife 28

SIMANTA HAZARIKA Son 10

Proof of Vending

Vendor ID Card Certificate Of Vending No. Letter Of Recommendation (LoR) No.

Address as per e-KYC

House No.* NAOKATA State* ASSAM

Town/Dist* MARIGAON Ward/Village* NAOKATA

PIN* 782105

Current Address

House No.* NAOKATA State* ASSAM

Town/Dist* MARIGAON Ward/Village* NAOKATA

PIN* 782105

Vending Activity
Name of Activity
Vending Activity* Fruits and Vegetables

Other

Place of Vending* Fixed Location

Duration of Vending* 09/2013

Location/Area of Vending

Stationary Vendor Vegetable Vendor near Kalimandir Nearest Landmark near Rupdan Studio

Mobile Vendor Nearest Landmark

State* ASSAM Town/Dist* MARIGAON

ULB Name* Marigaon Municipality Ward/Village* 6

Pin Code 782105

Avg. Monthly Sales (₹)

Avg. Monthly Sales (₹)* 24500

Bank Account Details

Name of Bank* Name of Branch* IFSC Code* Account No*

UNITED BANK OF INDIA ASSAM GRAMIN VIKASH BANK UTBI0RRBAGB 7273026005556

Digital Payment

Digital Payment Payment Aggregator UPI ID / VPA Durable QR Code

Loan Outstanding

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

Loan Amount Required

Loan Amount Required (₹)* 10000 Purpose Working Capital

Local References

Name Mobile No. Address

RUBUL KAKATI 9613629950 Naokata, Morigaon

MRINAL HAZARIKA 9954430708 NAOKATAT, MORIGAON

Benefits availed under other Govt. Schemes

Name Select

Ayusman Bharat – Pradhan Mantri Jan Arogya Yojana (PM-JAY)

Pradhan Mantri Matru Vandana Yojana (PMMVY)

Deendayal Antyodaya Yojana-National Urban Livelihoods Mission (DAY-NULM)

Pradhan Mantri Awas Yojana (PMAY) – Urban/Rural

Name Select

Pradhan Mantri Ujjwala Yojana (PMUY)

Integrated Child Development Services (ICDS)

Pradhan Mantri Jan Dhan Yojana

Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY)

Atal Pension Yojana (APY)

Pradhan Mantri Kaushal Vikash Yojana (PMKVY)

Seekho Aur Kamao

Upgrading the Skills and Training in Traditional Arts/ Crafts for Development (USTTAD)

Rashtriya Poshan Abhiyaan (RPA)

Pradhan Mantri Mtrutva Suraksha Abhiyan (PMMSA)

Swachh Bharat Mission (SBM)

Pradhan Mantri Sahaj Bijli Har Ghar Yojana (SAUBHAGYA)

National Food Security Act (Ration Card)

One Stop Centre

Pradhan Mantri Mudra Yojana (PMMY)

Pradhan Mantri Suraksha Bima Yojana (PMSBY)

Pradhan Mantri Shram Yogi Maan-dhan (PM-SYM)

Hunar se Rozgar tak initiative

Nai Roshni

Green Skill Development Programme

Other Schemes

Other Schemes Details :

None of the above

Declaration and Authorization:

a. I hereby certify that all information furnished by me/us 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. There is/are no overdue owed by me to any bank. The
information may also be exchanged by you with any agency, you may deem fit. You, your representatives or MoHUA, or any other agency as authorized
by you, may at any time, inspect/ verify my/our assets etc. You may take appropriate safeguards/action for recovery of lending institutions’ dues.
b. I have no objection to authenticate my Aadhaar number, share the same with other Ministries / Departments under the Government of India for the
purpose of extension of benefits under any of their Schemes, carry out e-KYC and accessing my credit history & credit score by credit bureau, lenders
and their authorized agents. The consent and purpose of collecting Aadhaar has been explained to me/us 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.

Date: 02/01/2021 Signature of Applicant(s)