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Union of India - Section
Section 19 in The Sovereign Gold Bond Scheme 2016 - Series II
19.
All other terms and conditions specified in the notification of Government of India in the Ministry of Finance (Department of Economic Affairs) vide number F. No.4(13) W&M/2008 dated the 8th October 2008 shall apply to the Gold Bond issued under this Scheme.Form 'A'[See Paragraph 5(i)]Application Form For Sovereign Gold Bond 2016 - Series II(Put √ wherever required)| Name of Bank/ Post Office | Name of Branch: |
| Mode ofSubscription | Cash | Cheque/ DD | Electronic Transfer |
| Gramsof Gold Applied for | Cheque/DemandDraft Drawn on (Name of the Bank & Branch) | Cheque/DemandDraft No. | Dated | |
| (in figure) | ||||
| (in word) |
| Amount : (in figures) | (in words) | ||||||||
| __________________________________________________________________ |
| Pan numberif applicable |
| Applicantstatus:Resident Individual[ ] Trusts [ ] Charitable Institution [ ] University Others[ ] Please specify: __ |
| Applicant(s) Detal(in block letters) | Existing Investor Id if any |
| First/ Sole Applicant's Name in Full |
| Applicant(s) Detal(in block letters) | ExistingInvestor Id if any | ||||||||||||||||||||||||||||
| First/ SoleApplicant's Name in Full | |||||||||||||||||||||||||||||
| Date of Birth (minor) | |||||||||||||||||||||||||||||
| Passport/Aadhar/ PAN/ TAN/ Voter ID No. (any one of the above) |
| Second Applicant's Name in Full |
| Passport/Aadhar/ PAN/ TAN/ Voter ID No. (any one of the above) |
| First/ Sole Applicant's/ Guardian's Address in Full (Do not fill in name again) |
| Contact Details |
| Phone | Fax | |||||||||||||||||||||||||||
| Bank Particulars for payment of interest | ||||||||||||||||
| Warrant/ Redemption | ||||||||||||||||
| Account Holder Name | Account No. | {| | ||||||||||||||
| Nominee details- Nomination Form (as applicable) to be filledand attached |
| Depository participant details(to avail of option tohold the bond in demat form) |
| Depository Name | NSDL | CDSL (For NSDL enter 8 digit dp ID followed by 8 digit clientID For CDSL enter 16 digit client ID) |
| DP/ Client ID |
| Declaration:I/We hereby declare and undertake that (i) my/our aggregateinvestment in Sovereign Gold bonds does not exceed 500 Gramsduring the financial year 2015-16 and (ii) the Informationfurnished in this application form is correct (iii) I have readand understood the details of information for the investors aswell as rights and duties of investors (copy attached). Theagent/bank has explained the features of the Scheme. |
| Signature | Signature | Signature |
| 1stApplicant | 2ndApplicant | Guardian |
| Date | {| | ||||||
| DateBank Stamp & Signature of the authorized official of thebank/ Post Office |
| Incase of thumb impression attestation by two witnesses |
| Thumb Impression |
| Witnesses: | |
| Name of 1stWitness ............................................................................................ | Name of 2ndWitness ............................................................................................ |
| Address ............................................................................................ | Address ............................................................................................ |
| ............................................................................................ | ............................................................................................ |
| ............................................................................................ | ............................................................................................ |
| Signature ............................................................................................ | Signature ............................................................................................ |
| H.U.F. Declaration(mandatory if applicant is Karta ofHUF) | |
| I ......................................................................................................................................................................................................residing at the address given against First Applicant do solmenlyaffirm that I am the karta of the Hindu Undivided Family and assuch have full powers to sell endorse transfer or otherwise dealin the sovereign Gold bonds 2016 – Series II standing inthe name of the HUF. | |
| Specimen signature for and on behalf of the HUF (name of theHUF) | |
| ............................................................................................ | |
| Place ............. | |
| Date ............. | |
| (Signature of the Karta with seal of HUF) |
| For Office use only | ||||||||
| Date of receipt of Application(DD/MM/YYYY) | BLA No. | CIF No. | Date of Credit to Government A/C(DD/MM/YYYY) | Nomination registered on(DD/MM/YYYY) | HUF declaration obtained (Y/N) | Total limit declaration obtained (Y/N) | NEFT/ECS mandate obtained (Y/N) | Any other information |