Account Opening Form for Individual (Part-1)

Customer Information Sheet (CIF Creation/Amendment)

(In case ofjoint accounts, Part-l(CIF) to be taken for each customer)

Date

1. Personal Details

1.Name *

2.Date of Birth* 3.Gender* Male Female Third Gender

4.Marital Status* Married Single Other

Father Mother Spouse (Father name is mandatory if PAN is not provided)

5.Name of*

6.Nationality* India Others Country Name______________________________________

7.Mobile No. 8.Email ID. ______________________________________________________________

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9.Alternative Mob No 10.Overseas Mobile and Tel No. (res/Off)

2. Proof of Identity/Address (Please tick the appropriate Box (any one ID type) and give details)*
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1.ID type*
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Passport Letter issued by national Population Register containing

(Mandatory in Voter's Identity Card Driving License NREGA Job Card
details of Name & Address
case of NRI/PIO)
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Proof of Possession of Aadhar No. (i) - E-KYC (ii) - Offline verification

2.Document identification Number*

3.Issued By
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4.Issue Date* 5.Expiry Date (If Applicable)

6.Visa/Work permit details*

(i).Issue Date* (ii) Place of Issue (iii) Expiry date

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3. Address Details* (as per Proof of Address submitted at 2. above)

1.Address Type* Residential/Business Residential Business Registered Office Overseas (mandatory for NRI/PIO)

2.Address*

3.City/Village* 4.District*

5.State* 6.Pin* 7.Country*

8.Is the address provided above your Current Address ?* Yes NO

If selected 'No', then please provide Current Address at S. No. 4 along with Documentary Evidence as per S. No. 3.)

4. Address Details Current / Local / Correspondence

1.Address Type* Residential/Business Residential Business Registered Office Unspecified

2.Address*

3.City/Village* 4.District*

5.State* 6.Pin* 7.Country*

8.Indian Address (Mandatory for NRI)

9.Please Tick where you would like to receive all correspondence Indian address Overseas address
5. If the Proof of Address/OVD provided does not contain current address, please provide any of the documents below
as OVD {Officially Valid Document)
1.Utility Bill* 2.PPO/FPPO* 3.Property or Municipal Tax Receipt*
4.Letter of allotment of accommodation issued by employer/issued by State or Central Government departments, statutory or regulatory bodies, Public Sector undertaking,
scheduled commercial banks, financial institutions and listed companies. Similarly, leave and license agreements with such employers allotting official accommodation. *
5.Self-Declaration (applicable only when customer has carried out e-KYC (AADHAAR Authentication) and address in AADHAAR is not same as Current Address)*

6.Document No*. 7.Date*

I/We shall submit OVD with updated Current Address within a period of three months, failing which bank may restrict the operations in the account.(Not Applicable when Self
Declaration is provided by the customer) (as per point No. 5 above)

6. Tax Proof

1.PAN*/Tax Identification Number or equivalent (If issued by jurisdiction) If PAN not submitted, fill form 60)

2.Country of Tax Residence in India only and not in any other country or territory outside India* Yes No (If No, please fill the FATCA details form-Annexure)

7. Income & Employment Declaration

1.Occupation Type* Private Sector Service Public/Govt. Sector Service Student Retired Self-Employed Not Working

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Other _____________________________________

2.Business Trader Jeweler Service Provider Agriculture Stockbroker Manufacturing Arms Dealer
(Only if Self-Employed)
Real Estate Others, Please Specify _____________________________________
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3.Annual Income* (Rs.)
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(Only if Self-Employed)

4.Organization Name(Only if Salaried)

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5.Designation Profession
(Only if Salaried)

6.Please tick the appropriate box* Politically exposed person Related to politically exposed person None
(Politically Exposed Persons are individuals who are or have been entrusted with prominent public functions in a foreign country e.g. Heads of State / Governments , Senior Politicians / Senior Government / Judicial /
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Military Officers, Senior Executives of State-owned Corporations, Important Political Party Officials, etc.)

8. Other Details
1.Religion Hindu Muslim Christian Sikh Others, please specify _____________________________________

2.Category General OBC SC ST Minority

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3.No. of Dependents 4.Illiterate Yes No If Yes : Identification Marks : _____________________________________

5.Residential Status* Resident Individual Non-Resident Individual Foreign National Person of Indian Origin

6.Customer Type/Status Sr. Citizen Staff PF No. Minor Pensioner

General Illiterate Ex Staff PF No. Pardanashin

7.Person with disability Yes No If Yes Visually Impaired Differently Abled

8.Education Qualification Below SSC SSC HSC Graduate Postgraduate Professional Others

9. Declaration Cum Undertaking Cum Self-Certification

I have read the copy of Terms & Conditions of the Account opening given to me. The Terms & Conditions have been explained to me/us and having understood, I accept the
same. I hereby declare that I have submitted the Aadhar Card issued by UIDAI voluntarily for identification and/or address proof towards the compliance of KYC norms under
the PMLA 2002.
I hereby consent that the bank may verify the same with the UIDAI and authorize the UIDAI expressly to release the identity and address through biometric authentication to
the bank.
Yes No (e-KYC authentication and Aadhar seeding is mandatory for availing DBT benefit )

Photo*
Signature/Thumb impression of the
Please Paste
Applicant Please sign in Black Ink
only
Recent Passport Size
Do not Staple

Place Date
 Account Opening Form for Individual
For SAVING BANK, CURRENT ACCOUNT
& FIXED DEPOSIT (in case of non-resident)

Bank/Branch to affix rubber stamp of name and code no. Date

FOR OFFICE USE

Fields marked (*) are mandatory. Please fill up in BLOCK letters only and use black ink for signature (Please tick in appropriate box)

Customer ID Application Type New Update

Account No.

CKYCR No .

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S No Check list
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1 Copy of PAN Card or Form 60 has been attached 10

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2 If country of Tax residence is not India, Annexure I (FATCA) has been obtained
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3 If applicant is a minor, duly filled annexure II has been obtained

I confirm that all details in the form, including Annexure I and Annexure II (if applicable), have been completed
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and duly checked
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5 I confirm in-person verification was carried out

I certify that self-certification & documents (POI & POA and others) received as part of account opening process
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have been verified from original and found correct & same is recorded on OVD's obtained

I certify that the implications and conditions for the operation of the account have been explained to the customer
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(only in case of illiterate applicant)
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8 I certify that applicant signature has been obtained in front of me and photograph has been verified in-person

9 Declaration for Converting Existing Resident account to NRO Account

Risk Category* High Medium Low

Documents Received Self Certified True Copies Notary Others

Details of one or two identification marks, if any, such as a mole or scar (mandatory for illiterate applicant) _______________________________________________

In person verification carried out and Signature/LTI of the applicant verified by:

Official Name: PF No. SS Designation SS

Date GBPA No Signature

_______________________________________________
 Part-II (Account opening form for
Non-Resident individual- For Saving Bank, Current Account & Fixed Deposit)
I/We request you to open my/our deposit Account with your branch/bank as under : (Tick relevant type of account)

1. Type of Account
Fixed Deposit
NRE Saving/Current/Fixed deposit NRO Saving/Current/Fixed deposit FCNR (B)
(Specify Currency and Period)
Payment & Maturity Instruction in case of FCNR (B) (a) Auto Renewal Required: Yes No
If Yes

Renew For Principal & Interest Renew For Principal only Period (Days/Months/Years) Number of times auto renewal required

If No
Transfer to A/c No Issue a Cheque Issue a DD

(b) Please credit interest to my NRE/NRO account no……………………or remit interest by DD/TT at my/our Indian/overseas address / Bank account
no…………………………….with……………………after deducting remitting charges, as may be applicable from time to time.

2. Facilities required (Please mark  in appropriate box/es): (Mobile No. is Mandatory for services from 1 to 7)
1. ATM CUM Debit Card
Yes No Name as would appear on the card

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1st Applicant
2nd Applicant
3rd Applicant
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(Available only for singly operated accounts and joint accounts operated by Either or Survivor mode. In case of accounts operated as Former or Survivor mode
IBS facility is available to 1st Applicant only)
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2. Cheque Book 3. Internet Banking View Transaction 4. SMS Alerts (Charges Applicable)

5. Phone Banking Services 6. Mobile Banking 7. e-statement (at of monthly intervals) in lieu of paper copy 8.Passbook
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(E-mail Mandatory)
The benefits of Nomination facility has been explained to me/us. However,
3. Nomination (If required fill form DA-1) Yes, (Fill form below)
I/We do not want to nominate any person in this account

FORM DA-1 (Nomination Form) Registration No.

Nomination under section 45ZA of the Banking Regulation Act, 1949 and Rules 1985 in respect of Bank Deposits
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I/We nominate the following person to whom in the event of my/minor's death the amount of this deposit, particulars of which are given below, may be returned by the Punjab
National Bank (Account Opening Branch)

I/We want the name of the nominee to be printed on the passbook

Details of Nominee

Name
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Mobile number of the Nominee Date of Birth of Nominee (in case of minor)

Relationship with the Customer ______ Age ______ Years

As receive the nominee amount is a of minor deposit on this on date, behalf I of the appoint nominee in Shri/Smt /Kum________________ Age ____ Years Address
______________________________________ to receive the amount of deposit on behalf of the nominee in the event of my/minor’s death during the minority of the nominee.
(Nomination in favor - of other than -individual is invalid)

Witnesses are required only in case of applicant is illiterate and if affixing thumb impression

Signature of First witness Signature of Second witness

Name ______________________________________ Signature _____________ Name ______________________________________ Signature _____________

Address __________________________________________________________ Address __________________________________________________________

Date _________________ Place __________________________

ACKNOWLEDGEMENT DA-1
We acknowledge receipt of nomination made by you in favour of: Signature of Bank Official

Name of the Nominee__________________________________ Age:______________ Years:______________

With respect to your Account Number

Registration No.
 ACCOUNT OPENING FORM FOR NON-RESIDENT INDIVIDUAL (PART-II)
For SAVING BANK, CURRENT ACCOUNT & FIXED DEPOSIT
Date

4. Declaration for Converting Existing Resident account to NRO Account

I/We hereby request the Bank to convert my/our existing resident Saving/Fixed Deposit/Current account as under to NRO Saving/NRO Fixed Deposit/NRO Current account
and hotlist all the international debit card linked to resident account.

Resident account No 1

Resident account No 2

Resident account No 3

5. Photo & Signature

The Branch Head Punjab National Bank
BO ________________________________________ D. No. ________________________________________
Savings / Current
I/We hereby agree to comply by the Bank's existing Rules as detailed in the passbook/AOF/Bank's Website, governing ___________________________________ accounts

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1st Applicant Name* CIF

2nd Applicant Name CIF

3rd Applicant Name CIF

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Self Either or Survivor
10 Former or Survivor Anyone or Survivor
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Mode of Operation

Jointly Operated Others ______________________

(Please Specify)
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Applicant 1 Recent Photograph Signature/Thumb impression of the Applicant 1 Signature/Thumb impression of the Applicant 1
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Applicant 2 Recent Photograph Signature/Thumb impression of the Applicant 2 Signature/Thumb impression of the Applicant 2
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Applicant 3 Recent Photograph Signature/Thumb impression of the Applicant 3 Signature/Thumb impression of the Applicant 3

Account ID

GBPA No./PF No.

Date
Full Signature of specimen witnessing officer
 TERMS & CONDITIONS & DECLARATION
1. I/We hereby declare that the details above in this form including details in Annexure 1 12. I undertake the responsibility to declare and disclose immediately and in no case beyond
and Annexure 2 are true and correct to the best of my/our knowledge and belief and 30 days from the date of change, any changes that may take place in the information
I/We undertake to inform you of any changes therein, immediately. In case of any of the provided herein/or otherwise, as well as in the documentary evidence provided by me or
above information is found to be false or untrue or misleading or misrepresenting, I /We if any certification becomes incorrect or undergoes a change. I further undertake to
am / are aware that I /We may be held liable for it. provide fresh and valid self-certification along with documentary evidence as and when
2. I /We agree to be bound by the terms & conditions, Instructions etc. as listed below so required nevertheless all declaration and undertaking given herein will also be
&Annexure FATCA/CRS and by the rules of Punjab National Bank and the RBI and any applicable to all such modified/amended document information provided by me unless
subsequent amendment(s). My/Our personal / KYC details may be shared with Central revised self-certification as above is provided to the Bank.
KYC Registry. I/We hereby consent to receiving information from Central KYC Registry 13. I also agree that my failure to disclose any material / information known to me now or in
through SMS / Email on the above registered number / Email address. future or my failure to remedy any deficiency in documents/information/other details
3. In case of FDR / RD in joint name with mode of operation Either or Survivor, any one within the stipulated period, may invalidate me from transacting in the account and the
can apply loan against the same. And anyone can also apply for premature payment / Bank would be within its right to put restrictions in the operations of my account or to
payment on maturity. close it or to report to any regulator and/or any authority designated by the Government
4. I/We hereby declare that in case of any credit facility is to be availed from any Banks/Fis of lndia(Gol)/RBI for the said purpose or take any other action as may be deemed
in the future, the same will be informed in advance. (Applicable when opening Current appropriate by the Bank under the guidelines issued by CBDT/RBI/Gol from time to time.
Accounts). 14. I also agree to furnish and intimate to the Bank any other particulars that are called upon
5. I affirm and declare that I have read over and understood the rules and regulations of me to provide on account of any change in law either in India or abroad in the above
the "Bank" and those relating to various services offered by the Bank including but not matter or otherwise.
limiting to debit card/internet banking/SM$ banking/Tele-Banking/Mobile Banking Virtual 15. I shall indemnify the Bank from any loss/damage that may be caused to the Bank on
Banking and any other facilities. I agree to abide by the same as amended/modified from account of any mistake in the details provided herein or on account of providing incorrect
time to time by the Bank/Regulator/Government published through circulars, or incomplete information by me.
notifications, notice board/websites/newspaper publications, etc. I waive the rights, if 16. I undertake to submit data/information together with fresh KYC documents for updating
any, to have personal notice in respect of such amendments/modifications. I agree that of KYC details at periodical intervals as may be required by the Bank.
the transactions and requests executed in my account(s}through internet, mobile, 17. I understand that the account will be activated, and debits will be allowed only after
telebanking or virtual banking under my User ID and password/PIN/OTP will be legally completion of Customer Due Diligence relating to KYC by the Bank.
binding on me & I am responsible for the maintenance of secrecy and confidentiality of 18. In case the account is opened without PAN, I undertake to submit PAN on or before
the authentication credentials and any other information/details/OTP/PIN, etc., in such such date as may be notified by the Government of India, failing which the account shall
matters. I agree that Bank has got all the rights to debit my account for any service cease to be operational till the time PAN is submitted, as per Prevention of Money -

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charge, expenses or other dues which the Bank is entitled/ liable to recover from me. I Laundering (Maintenance of Records ) Rules 2005.
also authorize the Bank and agree to close/discontinue my account without any notice to 19. In case, deemed OVDs are submitted for Current Address at the time of Account
me. I hereby undertake to inform the Bank on any change in my communication address opening, I undertake to submit Aadhaar or any of the OVD having Current Address
or constitution. within 3 months from the date of account opening, failing which I understand that my
6. In respect of accounts opened on the basis of Aadhaar details, I hereby declare that I account may cease to be operational as per GOI guidelines at the material time.
have submitted the Aadhaar Card issued by UIDAI voluntarily for identification and /or 20. I have received the Welcome Kit containing ATM card/cheque book and understand that
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address proof towards the compliance of KYC norms under the PMLA, 2002 and I
hereby consent that the Bank may verify the same with the UIDAI and authorize the
in case of any misuse/misplacement of the contents of the Kit, the Bank will not be liable
for any loss/damage.
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UIDAI expressly to release the identity and address through biometric authentication to 21. I hereby certify that the Savings Bank Account would be used by me to route
the Bank. I wish to seed this account with NPCI mapper to enable me to receive Direct transactions of only non-business/non-commercial nature. In the event of occurrence of
Benefit Transfer (DBT) including LPG subsidy from Govt of India (GOI) in this account. I such transactions or any such transactions that may be construed as
understand that if more than one benefit transfer is due to me, I will receive all the commercial/business/dubious or undesirable, the Bank reserves the right to unilaterally
benefit transfer in this account. freeze operations in such accounts and /or close the account.
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7. I confirm and declare that I am not prevented/prohibited/restricted by any applicable 22. I have been advised Quarterly Average Balance(QAB) requirement for the account to be
legal/regulatory/contractual or other provisions from opening and/or maintaining the opened and given to understand that these requirements are subject to revision/changes
accounts or to transact with the Bank in any other way. and such revision/changes will be uploaded in the Bank's site which will be acceptable to
8. I agree that my personal KYC details may be shared with Central KYC registry or any me as a notice to that effect.
other competent authority. I hereby consent to receive information from the Bank/Central 23. I acknowledge receipt of rules and regulations of Savings/Current/Fixed deposit Bank
KYC Registry/Gel/RBI or any other authority through SMS/e-mail on my registered Account.
mobile number/ e-mail address. I also agree that the non-receipt of any such SMS/e-mail 24. I/We have been advised that if I/We do not provide my/our mobile number, I/We will not
5

shall not make the Bank liable for any loss or damage whatsoever in nature. be eligible for any facility of electronic transactions.
9. I hereby certify that I have declared my status as per the rules applicable under section 25. I hereby declare that the details furnished above are true and correct to the best of my
285BA of the Income Tax Act, 1961 as notified by Central Board of Direct Taxes (CBDT) knowledge and belief and I undertake to inform you of any changes therein, immediately
vide Notification No. S.O. 2155(E) dated 7 August2015 and RBI Circular Ref No. in case any of the above information is found to be false or untrue or misleading or
DBR.AML.BC.No.36/ 14.01 .001/2015-16 dated 28August2015 in the matter including misrepresenting. I am aware that I may be held liable for it.
any subsequent modification/amendment thereof. 26. I/We confirm that the product features of account have been explained to me.
10. I understand, acknowledge and authorize that as per the provisions of Income Tax Act, 27. I/We hereby give consent for debiting my/our account for recovering service charges as
Rules made thereunder and the guidelines issued by the Government /RBI in the matter, normally applicable to Savings Bank and Current Account.
depending upon the residential status and/or other criteria stipulated therein, the Bank 28. I confirm and undertake that I will not deal in virtual currencies and will not use my
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may have to report the details in respect of my account(s) as per the prescribed format account for any services relating to virtual currencies or facilitate any person or entity in
to the Central Board of Direct Taxes (CBDT) or other Government Agencies to comply dealing with or settling Virtual Currencies.
with the obligations as per the Inter- Governmental Agreements (IGA) in respect of 29. I understand that in the event of failed Standing Instruction for Loan Repayment/
Foreign Accounts Tax Compliance Act (FATCA) and Common Reporting Standards dishonor of a cheque/NACH/ECS due to lack of funds / insufficient funds on 04
(CRS) and I or any other similar arrangements. occasions during financial year, no fresh cheque book would be issued, closure of
11. I certify & declare that the information provided by me for opening loan account and account may also be considered.
availing other services herein or through website/electronically as applicable to me 30. Documentary evidence must be submitted for proof of Annual Income/ Annual Turnover.
signed/authenticated by me as well as in the documentary evidence provided by me for Bank will set Account level Threshold limit based on expected Annual Credits declared
opening loan account and availing other services are, to the best of my knowledge and by the customer. In case, Self Declaration is submitted for Annual Turnover/ Income/
belief, true, correct and complete and that I have not withheld any material information expected Annual Credits, lower Threshold limit, as decided by the Bank from time to time
that may affect the assessment categorization of my account as a U.S. Reportable will be fixed and If Threshold Limit is breached, further credits will not be allowed in the
Account or Other Reportable Account or otherwise. In case any of the information or Account till the lime documentary evidence is submitted by the Customer.
details provided by me is found to be false or untrue or misleading or misrepresenting, I 31. I/We authorize Punjab National Bank to share my/our KYC details for cross selling of its
am aware that I may be held liable for it. products in routine course of its banking and related business undertaken by bank and
for any other purposes permitted by regulators from time to time.
 TERMS & CONDITIONS & DECLARATION
1.Seafarer Declaration : I/We hereby declare and confirm that I am/we are Non-Resident 3.I/We agree to abide by the provisions of NRO/NRE/FCNR (B) account. I/We hereby
and I am/we are presently on contract with a foreign registered company, details of undertake to intimate you about my/our return to India for permanent residence
which are provided in the documents submitted. I/We also confirm that I/We will inform immediately on arrival, to re-designate my/our existing NRO/NRE/FCNR (B) account to a
the Bank, in case I/We do not renew my/our contract or chose to go on a new contract or resident Indian account or RFC account as applicable.
I am /We are unable to proceed on a new contract or in any case in the event that 4.I/We hereby declare that I am/we are NRI(s)/PIO(s)/OCI(s) and not residents of any
my/our status of Non-Resident Indian is altered. Accordingly, I/We will have the Non- country where opening or maintaining of the account is prohibited by the law and
Resident accounts opened in my/our name re-designated to Resident account as regulatory requirement of such country or by the applicable laws in India or by RBI. I/We
applicable. understand that the above account will be opened on the basis of the
2.I/We hereby declare that all foreign exchange transactions as are being entrusted and statements/declarations made by me/us and I/We agree that if any of the
may be entrusted by me/us to the Bank from time to time do not/will not involve and are statements/declarations made herein is found to be incorrect in material particulars, I/We
not/will not be designed for the purpose of any contravention or evasion of the provisions are not eligible for any interest on the deposit made by me/us and the account may be
of the PMLA or FEMA, 1999 or of any rule, regulations, notification, direction or order closed.
made there under. I/We also hereby agree and undertake to give such 5.I/We hereby agree that the transactions in the above account will be governed by
information/documents as will reasonably satisfy you about the transaction in terms of applicable laws in India and all the disputes or differences arising out of or related to or
above regulation. I/We also undertake that if I/We refuse to comply with any such connected with transaction or matters in relation to the above account shall be subject to
requirement or make untenable complaint there against, the Bank shall be within its right exclusive ‘Jurisdiction of Indian Courts’.
to refuse in writing or otherwise to undertake the transaction and shall, if it has reason to 6.I/We agree that if premature withdrawal is permitted at my/our request, the payment of
believe that any contravention/evasion is contemplated by me/us, report the matter to interest on the deposit may be allowed in accordance with the prevailing stipulations, laid
Regulator/or otherwise also, as and when demanded by them. down by the RBI/Bank in this regard.

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Signature/Thumb impression Signature/Thumb impression Signature/Thumb impression

of Applicant 01 of Applicant 02 of Applicant 03
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5
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 Nature of Documents for NRl's

Passport mentioning Name, Date of Birth, Place of issue, Expiry date,

Proof of Identity
photograph & Signature mentioned.

Anyone of the following:

1. For NRls: Any one of the following
a) Valid Visa/Work Permit
b) Valid Job Contract
c) Valid Continuous Discharge Certificate (CDC)
d) Last pay slip evidencing employment with a shipping company (not more
than 6 months old)
2. For Foreign National & Foreign National Students
Proof of Status
a) Valid Indian Visa/Tourist/Business Visa/Long Term Visa
b) Passport
c) FRRO/FRO copy
d) University/College Admission letter
3. For PIOs/OCI: Any one of the following
a) PIO/OCI Card
b) Marriage Certificate evidencing spouse's India Origin
c) Passport of parents or grand-parents evidencing their Indian Origin

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Anyone of the following:
a) Passport mentioning India address
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Proof of Indian address
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b) Aadhar letter/card
c) Voter Identity Card
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d) Driving License
e) Job Card issued by NREGA
f) Any other proof as applicable for Resident Indians
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Anyone of the following:

a) Passport mentioning Overseas address
b) Government issued National Identity card at the country of residence
5

c) Valid employment letter/contract

d) Permanent Resident permit/Work permit mentioning overseas address.
Proof of Overseas address
e) Bank statement of Overseas or Indian based bank (not more than 3
months old)
f) Employer's certificate for proof of overseas address
g) Driving License issued abroad
h) Utility Bill (Electricity, Telephone, Gas)
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Anyone of the following:

a) Certificate of residence or any valid identification issued by an authorized
Proof of Tax Government body.
b) Relevant documents where Tax Identification
Number(TIN)/Citizen/personal Identification code etc. are mentioned.

For applicant who is not visiting By Anyone of the following:

our Branch for opening of account 1. Authorized official at PNB foreign office
(saving/current), third party 2. Notary public
attestation is mandatory. 3. Indian Embassy or High Commission
 अनुबंध 1 - ि य के िलए एफएटीसीए /सीआरएस व स यापन /घोषणाप
कृ पया कर योजन और संबंिधत िववरण के िलए उन सभी दश
े का उ लेख कर जहां के आप िनवासी ह|

ाहक आईडी सीके वाईसी नं.

खाता सं.
नाम *

नाग रकता * भारत म अ य दश

े का नाम:

ज म का थान/शहर * ज म का दश
े *

पता*

शहर/गाँव* िजला*

रा य* िपन*

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कर िनवास का दश
े # कर पहचान सं या या अिधकार े ारा जारी उसका समतु य पहचान का कार (टीआईएन या अ य, कृ पया िविन द कर)

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@ * यूएस म ज म ले कन दस
ू रे दश
े म िनवास करने वाले ि (िजसने यूएस क नाग रकता नह छोड़ी ह)ै सिहत यूएस का नाग रक
* यूएस ीन काड धारक सिहत यूएस म िनवास करने वाला ि *ऐसे ि जो येक वष यूएस म 180 दन से अिधक का समय तीत करते ह|
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भारत के बाहर अिधकार े /दश

े का पता - जहां आवेदक कर योजन के िलए िनवासी ह|ै

पता*

उप-िजला: िजला*: रा य*:

दश
े का नाम* िजप/ पो ट कोड*

ख) घोषणा/ स यापन

झूठी गवाही के दड
ं के तहत, म मािणत करता/करती ँ क: म समझता/समझती ँ क एफएटीसीए/सीआरएस के अनुपालन म उपरो खाताधारक क ि थित का िनधारण करने के उ े य से पंजाब
नैशनल बक इस सूचना पर िनभर ह|ै पंजाब नैशनल बक एफएटीसीए या सीआरएस पर कोई कर सलाह या खाताधारक पर इसके भाव क पेशकश करने म स म नह ह | कर संबंधी कसी भी सवाल
के िलए म पेशेवर कर सलाहकार से सलाह लूंगा | इस फाम म कही भी जानकारी या माणीकरण गलत हो जाने पर 30 दन के भीतर नया परप जमा करने पर सहमत ँ |

म मानता ँ क घरे लू िनयामक / कर ािधकरण ारा जैसा आव यक हो , पंजाब नैशनल बक को भी सीबीडीटी या अ य ािधकरण / एजिसय
, को रपोट करने यो य िववरण, रपोट करने और मेरे
खाते को, बंद करने या िनलंिबत करने,जैसा उिचत हो, क आव यकता हो सकती ह|ै

मने इस फॉम क सूचना संबंधी अपे ा ( एफएटीसीए/ सीआरएस िनदश के साथ प ठत) को समझ िलया है और एत ारा इस बात क पुि करता ँ क इस फॉम म मेरे ारा दान क गई जानकारी,
िजसम करदाता पहचान सं या भी शािमल ह,ै स य, सही, और पूण ह|ै म यह भी पुि करता ँ क मने एफएटीसीए/ सीआरएस के िनयम और शत को पढ़ एवं समझ िलया है तथा एत ारा उसे
वीकार करता |ँ

थान
ह ता र

दनांक

PNB-1249A2 ANX I_APR22_4_Ver1.0_APR22_SESHAASAI

1
 Annexure I - FATCA/CRS SELF CERTIFICATION / DECLARATION FOR INDIVIDUALS*

Please indicate all countries in which you are resident for tax purposes and associated details.

Customer ID: CKYC: No.:

Account No.

Name*

Citizenship* IN-India Other, Country Name:

Place/City of Birth* Country of Birth*

Address*

City/Village*: District*:

State:* Pin:*

:24
Multiple Tax Residency Details of Country of Tax Residence in India, and/or in US @ And/or in any other Country or Territory Outside India as Under:

Country of Tax Residence # Tax Identification number or equivalent if issued by jurisdiction Identification type (TIN or Other, please specify)

24 7
10
-20 01
-09 77

@ * A citizen of US including individual born in US but resident in another country (who has not given up US citizenship)
* A person residing in US including US green card holder * Certain persons who spend more than 180 days in US each year
24 51

Address in the Jurisdiction/Country-where the Applicant is Resident outside India for T ax Purposes

Address*

Sub-District: District*: State:*

Country Name* ZIP/Post Code*

B) Declaration / Certification

Under penalty of perjury, I certify that : I understand that Punjab National Bank is relying on this information for the purpose of determining the status of the account holder
named above in compliance with FATCA/CRS. Punjab National Bank is not liable to offer any tax advice on FATCA or CRS or its impact on the account holder. I shall seek
advice from professional tax adviser for any tax questions.

I agree to submit a new form within 30 days if any information or certification on this form becomes incorrect.
I agree that as may be required by domestic regulators / tax authorities, Punjab National Bank may also be required to inform reportable details to CBDT or other authorities /
agencies or close or suspend my account, as appropriate.

I have understood the information requirements of this Form (read along with the FATCA /CRS Instructions) and hereby confirm that the information provided by me on this
form including the taxpayer identification number is true, correct and complete. I also confirm that I have read and understood the FATCA /CRS Terms And Conditions and
hereby accept the same.

Place
Signature

Date