FINANCIAL INCLUSION ACCOUNT OPENING APPLICATION FOR INDIVIDUALS

Affix Photograph

(To be captured through

system or obtain latest

photograph not older

than six months

Name of the branch

Village/ Town

Village code/Town code :-(As per census 2011)

Name of Village/Town:-(As per census 2011)

Ward Number District

State

Sub District/Block Name

Application No.

Date:

APPLICANT DETAILS :

CONTACT DETAILS (Please do not sign before filling up this section)

Full Name

Prefix

Married

Indian Foreign National

Foreign National

Single Others Male Female Transgender

First Name Middle Name Last Name

Maiden Name

Father/Spouse Name

Mother Name

Date of Birth Place of Birth

Non-Resident Indian

Not Applicable

Driving Licence Expiry Date

Person of Indian Origin

Yes (If yes, kindly fill form 60)

Marital Status

Nationality

Residential Status

G - Other Identity Proofs (Notified by Govt.)

A - Passport Number

B - Voter ID Card

C - PAN Card

D - Driving Licence

E - NREGA (Job Card)

F - Aadhaar (Physical Copy)(not-mandatory)

Permanent Account Number(Please fill Form 60 field)

Gender

Form 60

Proof of Identity:(any one of them)

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Please note: We currently do not offer Account Opening to residents of the U.S. State of California. If you have any queries, please contact the hotline +1-833-971-1191 (United States) for more details

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Mobile Number Landline Number +91

STD Code

E-mil ID

Current ResidentialAddress

Permanent Address

City District

District

Country

PIN

PIN

City

State

State

+91

Fax

By submitting a copy of my/our Proof of Possession of Aadhaar Number, containing Aadhaar number, I/We confirm and agree that the Bank has duly explained to me/us that submission of Proof

of Possession of Aadhaar number is no longer mandatory and I/We have the option to submit any one of the documents as per the list of Officially Valid Documents (updated by the RBI from time

to time) towards submission of KYC/proof of address documents. If I/We provide such Proof of Possession of Aadhaar number containing my/our Aadhaar number, I/We note that (i) I am/We are

providing the same as an officially valid document voluntarily in accordance with extant rules and regulations; (ii) I am/We are required to redact/ blacken out the first eight digits of Aadhaar number

such that only last four digits of the Aadhaar number are visible; and (iii) in case I/We do not redact/ blacken out the first eight digits of Aadhaar number, it shall be deemed that I/We have authorized

Citibank to redact/blacken out the same on my/our behalf.

Prefix First Name Middle Name Last Name

Prefix First Name Middle Name Last Name

Name of the branch:No. of Dependents

CKYC Address Proof Expiry Date

Kisan Credit Card(Whether Eligible):

I request you to issueme a RuPay card

Existing Bank account of Family member/ household

Any other:

OTHER DETAILS

CKYC DETAILS

CKYC Occupation CKYC Address Type

CKYC Address Proof CKYC Address Proof No.

Religion Caste

Detail of Assets Owning Farm:Owning House: Yes No

Yes No Yes No Yes No

Yes NoNo. of Animals:

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If yes, please mention No. of A/Cs:

Mother Name

Father Name

CKYC Address

I also understand that I am eligible for an Overdraft after satisfactory operation of my account after 6 months of opening my account with a Limit up to`10000/- (Rupees Ten Thousand only) for meeting my emergency/family needs subject to the condition that only one member from the household will be eligible for overdraft facility I shall abide by the terms and conditions stipulated by the Bank in this regard.

Citizenship CKYC Effective Date

Organization Name

Designation

Name (Same as ID Proof)

Maiden Name (If any)

Father / Spouse Name

CKYC Expiry Date

Landline Number +91

District

STD Code

PIN

City

State

Occupation Type

Company Name

Office Address

Designation

Service Private Sector Public Sector Government Sector Others

Business

Professional Retired Housewife

Not Categorised

Gross Annual Income (`)

If Self EmployedStudent

EMPLOYMENT DETAILS

Mother Name

KYC Number (If available)

Accoint Number

Nationality Indian

Male Female Transgender

Others

Professional

Date of Birth

Form 60

Single

Post Graduate

Foreign National (Please specify)

Foreign National Person of Indian Origin

Yes Not Applicable

Others (Please specify)

Married

Graduate

Resident Individual

Gender

Marital Status

Education

Residential Status

Permanent Account Number

(Please fill form 60 field)

Relationship withPrimary Applicant

(Please leave one space between each name)

(If 2nd applicant is Citibank Account holder)

(If yes, kindly fill form 60 on Annexure page 1)

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Proof of Identity

Proof of Address

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Please note: We currently do not offer Account Opening to residents of the U.S. State of California. If you have any queries, please contact the hotline +1-833-971-1191 (United States) for more details

FOREIGN ACCOUNT TAX COMPLIANCE ACT (FATCA)

DECLARATIONI hereby apply for opening of a Bank Account. I declare that the information provided by me in this application form is true and correct. The terms and conditions applicable have been read over and explained to me and I have understood the same. I shall abide by all the terms and conditions as may be in force from time to time. I declare that I have not availed any Overdraft or Credit facility from any other bank. I am resident of India and I undertake to intimate the bank in case of change in my residency status. I hereby consent for sharing/ receiving information with/ from Central KYC registry through SMS on the above registered number.

FACTA & CRS Related Certification - cum Undertaking for Individuals

CRS Notice and Declaration

SIMPLIFIED CRS SELF-CERTIFICATION FORM FOR INDIVIDUALS

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Citibank India does not market any product or service to individuals resident in the European Union, European Economic Area, Switzerland, Guernsey, Jersey, Monaco, San Marino, Vatican, and The Isle of Man. This application form is not, and should not be construed as, an offer, invitation or solicitation to buy or sell any of the products and services mentioned herein to individuals resident in the European Union, European Economic Area, Switzerland, Guernsey, Jersey, Monaco, San Marino, Vatican, and The Isle of Man.

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I hereby declare that what is stated above is true to the best of my knowledge and belief:

Applicant Signature

Date: Place

I, the holder of Aadhaar number: , submit my Aadhaar number and hereby voluntarily given my consent to Citibank

2019

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