Statement of Assets and Liabilitiest

To,
IDBI BANK LIMITED

_____________ Branch
Statement Of Assets and Liabilities as on _____________
1 Name of the Borrower/Co-

Borrower/Guarantors
2 Nationality
3 Father's/Husband Name
4 Present Address (with pin
code)
5 Permanent Address (with pin
code)
6 Telephone No
7 Mobile No
8 Date Of Birth
9 Occupation Service/Business/Others (Specify)
10 If in Service
Name of the employer
Address/Tel No
Service Since
Post held
11 If in Business
Name of the Firm
Address/Tel No
Established Since
Line of Activity
Experience
Position
12 Annual Income (As per ITR

Dated ---/---/----)
13 PAN No
Net worth statement
14. Bank Account Details

(Rs. in Lakh)
Bank Branch SB/CA/ Present Balance Avg Bal in last 6
CC/OD (As Months
A/c No. On ----------------)
15. DETAILS OF ASSETS
A. IMMOVABLE PROPERTY (Amt. in Rs. Lakh)

Assets Own / Area Free Location/ Purchase Present Whether
Joint (Sq Hold Address Cost Value Encumbered
Name Ft) or (Give details)
Lease
Hold
Non Agri. Land
i. Commercial
ii. Residential
Flat / House
Agri. Land
Others
Whether Self occupied / Rented / Leased out (Give details):

______________________________________________
B. MOVABLE PROPERTY:
(i). Term Deposits: (Amt. in Lakh)

Deposit Bank/Branch Amount & Date of Maturity date Maturity
Receipt No. Name Receipt amount
2
Net worth statement
(ii). Investment in Govt. securities like Bonds / PPF/ NSC / KVP / IVP etc.
(Amt. in Rs. Lakh)
Nature of Certificate Dt. of Issuing Face Due date Maturity
Securities. No Purchase Office/ value amount
Post
office
(iii) Insurance Policies (Amt. In Lakh)

Name of Company Policy Dt. Sum Surrender Annual Premium paid
No of Assured Value Premium Up to what period
Issue
(iv) Shares / Debentures / Mutual Fund etc. (copy of Demat Statement to be enclosed)
(Amt. in Rs. Lakh)
Name of No. Of Certificate No./ A/c If charged/ Current Market
Company Shares/ No./ Pledged, the value
Demat Account No. Nature and extent
Of charge/ pledge
(v). Vehicles: (Amt. in Rs. Lakh)

Type of Registration Model Year of Cost at the time RC Book Present
Vehicle No. make of Purchase Details value
3
Net worth statement
(vi) Other Movables (Amt. in Rs. Lakh)

Description Quantity Valuation (approx)*
(* Attach Valuation certificate, if available)
(vii) Other Investment in business
Name of the Firm Amount of As per Balance Sheet dated (--/---/----/)

Investment
16. Details of Liabilities

i. As Borrower: (Amt. in Thousands)
Name of the Purpose of Amt. of Repayment Outstanding Balance
Bank Loan Loan Security Terms (As on --/---/----/)
ii. As Guarantor: (Amt. in Thousands)

Name of the person/ Name of the Guarant Present Status Outstanding
Company to whom Bank / ee of Balance
Guaranteed Financial Amount Account (As on --/---/----/)
Institution (Rs.) (Performing/
NPA)
Actual Net Worth: _________________________

To the best of my/our knowledge I/we hereby declare that above statement given by me/us
are correct
Place ................................. ------------------------------------------

Date ................................. Signature (Borrower/Guarantor)
4
Net worth statement
Net Worth* assessed as per market In case of Guarantor, Signature verified

report and the details provided by the (By the Borrower)
Borrower,
Rs. _________ (Bank Official)
Verified the documents (with the
original) -----------------------Borrower’s
By ........................ Signature
-----------------------
Signature & Code Date: .................
Date: ………..
Enclosure (in support of above declarations):

i. Balance Sheet, Profit & Loss Account, Trading Account, Capital Account
(Audited / Unaudited)
ii. Copy of Employment Certificate with details of salary drawn.
iii. Copies of Agreement / revenue records / Tax paid receipt/society certificate in
respect of Land/building/flat owned by me.
iv. Copies of Income Tax / Wealth Tax Returns / PAN Card / Assessment Order along
with proof of payment
v. Other relevant documents.
Certified by CA. _____________________

(For cases having overall exposure above Rs.1 crore)
Date: Place:

Statement of Assets and Liabilitiest

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Statement of Assets and Liabilitiest

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To,

IDBI BANK LIMITED

Statement Of Assets and Liabilities as on _____________

1 Name of the Borrower/Co-

12 Annual Income (As per ITR

14. Bank Account Details

15. DETAILS OF ASSETS

A. IMMOVABLE PROPERTY (Amt. in Rs. Lakh)

Whether Self occupied / Rented / Leased out (Give details):

(i). Term Deposits: (Amt. in Lakh)

(iii) Insurance Policies (Amt. In Lakh)

(v). Vehicles: (Amt. in Rs. Lakh)

(vi) Other Movables (Amt. in Rs. Lakh)

(* Attach Valuation certificate, if available)

(vii) Other Investment in business

Name of the Firm Amount of As per Balance Sheet dated (--/---/----/)

16. Details of Liabilities

ii. As Guarantor: (Amt. in Thousands)

Actual Net Worth: _________________________

Place ................................. ------------------------------------------

Net Worth* assessed as per market In case of Guarantor, Signature verified

Enclosure (in support of above declarations):

Certified by CA. _____________________

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