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Union of India - Section
Section 19 in The Sovereign Gold Bond Scheme 2016-17 - Series IV
19.
All other terms and conditions specified in the notification of Government of India in the Ministry of Finance (Department of Economic Affairs) vide F. No.4(13) W&M/2008, dated the 8th October, 2008 shall apply to the Gold Bond issued under this scheme.By Order of the President of IndiaApplication form for Sovereign Gold Bond 2016-17 - Series III(Put √ wherever required)| Name of Receiving Office | Name of Branch : |
| Mode of Subscription | Cash | Cheque/ DD | Electronic Transfer |
| Grams of Gold Applied for | Cheque/ Demand Draft Drawn on(Name of the Bank & Branch) | Cheque/ Demand Draft | Dated | |
| (In Figures) | ||||
| (In words) |
| Amount: Rs. (in figures) (in words) | |||||||||
| _____________________________________________________________ |
| PAN number if applicable |
| Applicant status:Resident Individual [ ], Trusts [ ], Charitable Institution [ ], University [ ], others [ ], Please specify: _____ |
| Applicant(s) Detail(in block letters) | Existing RBI Investor ID, if any |
| First/ SoleApplicant's Name in Full | ||||||||||||||||||||||||||||||
| Date ofBirth (minor) |
| Second Applicant's Name in Full |
| Passport/Aadhar/ PAN/ TAN/ Voter ID No. (any one of the above) |
| Guardian (in case of minor) |
| 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 | |||||||||||||||||||||||||||
| BankParticulars For Payment of Interest Warrant/ Redemption | |||||||||||||||||
| AccountHolder Name | |||||||||||||||||
| Bank Name Account No. | {| | ||||||||||||||||
| Account Type | SB Account | Current Account | |
| Nominee details – Nomination Form (as applicable) to befilled and 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 client ID,For CDSL enter 16 digit client ID) |
| DP/ Client |
| Declaration:I/ We hereby declare and undertake that (i) my/ our aggregate investment in Sovereign Gold Bonds 2016-17 - Series II does not exceed 500 Grams during the financial year 2016-17 and (ii) the Information furnished in this application form is correct, (iii) I have read and understood the details of information for the investors as well as rights and duties of investors (copy attached). The agent/ bank has explained the features of the scheme. |
| Signature | Signature | Signature |
| 1stApplicant | 2ndApplicant | Guardian |
| Date | {| | ||||||
| Date,Bank Stamp & Signature of the authorized official of thebank/ Post Office |
| In case of thumb impression, attestation by two witness |
| Thumb Impression |
| Witnesses: | |
| Name of 1st Witness _________________________ | Name of 2nd Witness _________________________ |
| Address ___________________________________ | Address ___________________________________ |
| ___________________________________ | ___________________________________ |
| ___________________________________ | ___________________________________ |
| Signature __________________________________ | Signature __________________________________ |
| H.U.F. declaration(mandatory, if applicant is Karta of HUF) |
| I,..........................................................................................residing at the address given against First Applicant, dosolemnly affirm that I am the Karta of the Hindu Undivided Familyand as such have full powers to sell, endorse, transfer orotherwise deal in the Sovereign Gold bonds 2016-17 – SeriesII, standing in the name of the HUF. |
| Specimensignature for and on behalf of the HUF (name of the HUF)............................................................................................................... |
| Place : ____________________ | |
| Date : _____________________ | (Signature of the Karta with seal of HUF) |
| Date of receipt of Application (DD/MM/YYYY) | BLA No. | CIF No. | Date of Credit to Govt. 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 |