a/c

F - 349 for Guarantor

INDIAN OVERSEAS BANK Branch:____________________ ASSETS & LIABILITY STATEMENT From To The Branch Manager Indian Overseas Bank Branch: Date :

Dear Sir, Ref. : Application for credit facility submitted by M/S for Rs. ....................................................................................... With reference to the above loan application, I furnish hereunder my personal information and details of my Assets and Liabilities in Table A and Table D. I also enclose copies of my Tax Returns / Assessment Order / Salary Certificate / Encumbrance Certificate of my property for your record. I hereby declare that the particulars furnished by me hereunder are true to the best of my knowledge.

Yours faithfully,

Signature

a/c 02 TABLE : A-- PERSONAL INFORMATION A.1 A.1a A.2 A.3 A.4 A.5 A.6 NAME Dt. of Birth & Age Fathers Name / Husbands Name (in case of Married women) Residential Address & Tel. No. Office Address & Tel. No. PAN & IT Circle Name of Employer / Nature of Business / Profession Position held now Particulars of Previous employment, if any Monthly Emoluments (if in service) Cross Income LESS Deductions Per Month Rs. Per Month Rs. 1. 2. Earning From Profession/Business Gross Income Less Expenses Per Annum Rs. lac 1 A.11 Per Annum Rs. Lac 2 :

F - 349 for Guarantor

A.7 A.8 A.9

Net Emoluments per Month Rs. 3.

A.10

Net Earning Per Annum Rs. Lac 3

Name, Address & Tel. No. of my

present Banker A.12 Details of Guarantee already executed by me Name of Principal Name of Guarantee Beneficiary Amount Debtor 1 2 3 03

Guarantee Valid upto 4

Remarks 5

a/c A.13 Details of Credit Cards held Name of Bank Card Limit 1 2

F - 349 for Guarantor

Nature of Card 3

Dues as on date 4

TABLE : B ASSETS B. 1 Immovable properties S.No. Name of the Owner Depreciation of Property 3 Location/Address of Extent of property (please furnish land full details with survey No. Door No. etc.) 4 5

1 1. 2. 3. 4. Extent of Building area constructed 6

Type of property i.e. whether residential / agricultural / Industrial / commercial, etc., 7

Details of documents conferring right 8

Date of purchase of property 9

Original Purchase cost Rs. Lac 10

Present market value Rs. Lac 11

Details of encumbrances, if any, on the property 12

Total 04 B.2 Machineries

a/c Installed at Short descrip tion 2 Book Value Rs. Lac 3 Depreciated value Rs. Lac 4

F - 349 for Guarantor Appr. Market Value Rs. Lac 5 Encumbrance of any 6

B. 3 Deposits held with companies / others S. No. 1 Name of the company 2 Nature of Deposit 3 Amount Rs. lac 4

B. 4 Life Insurance Policies Date of policy 1 Policy No. 2 Whether Endowment policy or while life policy or other 3 Annual premium Rs. 4 Sum Assured Rs. Lac 5 Surrender Value (Rs. Lac) 6

TOTAL B. 5 Govt. Securities / NSCs / Shares of Listed Companies S. No. 1 1 2 3 4 5 6 7 8 9 Description of Security 2 Face Value (Rs. lac) 3 Market Value (Rs. Lac.) 4

TOTAL 05

a/c B.6 Investments in Business Sl. No. Name of the company / firm / concern in which investment is made 1 2 1 2 TOTAL B.7 Sl. No. 1 1 Deposits held with Banks Name of the Bank 2 TOTAL B.8 Vehicle Owned Description of Regn. No. Vehicle 1 2 Nature of Deposits held 3

F - 349 for Guarantor

Amount invested (Rs. Lac) 3

Amount Deposited (Rs. lac) 4 0.20

Original Cost (Rs. lac) 3

Depreciated Value (Rs. lac) 4

Appr. Market Value Rs. lac 5

Insurance company 6 B. 9 Sl. No. 1 1 2 B.10 Other Assets Owned

RC book in the name of 7

Encumbrance if any 8

Nature Description of assets 2 TOTAL

Original Cost Depreciated Rs. lac value Rs. lac 3 4

Approximate Market Value Rs. Lac 5

Encumbrance if any 6

TOTAL ASSETS (B.1 TO B.9)

: Rs.

lac

06

a/c TABLE : C C.1 LIABILITIES

F - 349 for Guarantor

Borrowings from Banks and Financial Institution Details of Nature & extent of credit limit / facilities enjoyed Nature of Credit facilities Extent (Rs. lac) 2.1 2.2 Details of securities furnished 3

Nature of the Institution / Bank 1 C.2

Borrowings from others Amount borrowed (Rs. lac) 2 Details of securities furnished 3

Name of the Lender 1 C.3

Other Liabilities Nature of liabilities 1

Extent of liabilities (Rs. Lac) 2 : Rs. Lacs

C.4 TOTAL LIABILITIES (C.1 TO C.3)

TABLE: D

NETWORTH TOTAL LIABILITIES D.2 Rs. Lac NET WORTH (D.1 minus D.2) Rs.

TOTAL ASSETS D.1 Rs lacs

lac

07

a/c TABLE E : E.1 DECLARATION AND UNDERTAKING

F - 349 for Guarantor

I hereby declare that the assets referred above (Table : B) are owned by me and these assets are not alienated or encumbered except to the extent furnished in the statement. Further I hereby undertake, not to encumber / alienate the said assets without prior intimate to Bank in writing till all my obligations to Bank are fully discharged. I/We also declare that I am not facing any litigations initiated by other banks/ financial institutions and there are no recovery proceedings for arrears of Income Tax, Sales Tax, Customs duty, Excise duty etc. I declare that neither any insolvency / winding up proceedings nor any court case is pending against me in my capacity either as borrower or as guarantor.

E.2

E.3

(In case any litigation with other bank is faced or winding up proceedings / court case is pending, the details thereof should be furnished) Nature of Litigation Brief Particulars 1 2 Nil E.4 I am agreeable to the condition that your Bank will have unqualified right to disclose / publish my name is such manner and through such medium as the bank in their absolute discretion may think fit in the event of default by myself.

Date : Place:

Signature of Applicant

08

a/c

F - 349 for Guarantor

TABLE : F 1.1

FOR BRANCH USE

We certify that we have verified the information furnished above, with the relative records wherever it is applicable and the assessment made is true and fair to the best of our knowledge and belief. Copies of supporting documents as listed here below have been obtained and held as branch record. List of documents / Papers received

1.2

S.No. 1. 2. 3. 4. 5.

Any other remarks:

Signature of the Branch Manager. Branch ..