ALLAHABAD BANK
Account Opening Form Supplement (Individual-Other than Entity)
(For identification of account holders for the purpose of reporting under section 285BA of
the Income-tax Act 1961 )
(To be attached to account opening form for obtaining information from new customers. Such form should be filled up
by existing customers also as required by the Bank from time to time.
In case of Joint account/accounts operated by more than one individual, the form should be submitted by each person
for separate CIF.
Please fill-up in BLOCK Letters
New Customer / Existing Customer (Please provide tick ())
1.
2.
3.
4.
5.
Name of Account: …………………………………………………………………………………………………………………………..
Account Type (Deposit/Loan/Demat/Others) :…………………………………………………………………………………….
Account Number: ………………………………………………………………………………………………………………………………
Name of account holder/Operator :……………………………………………………………………………………………….
CIF Number: ………………………………………………………………………………………………………………………………………
 Please provide Tick () in correct places. If Yes, please provide details at appropriate place below)
Yes
USA
Other Country (Specify
Name of country)
India
Country of tax Residence#
Country of Birth
Place of Birth
#If Yes, please indicate all countries in which you are resident for tax purposes and the associated Tax Reference Number below—
Name of Country of tax
Residence @
Tax Reference Number/ Tax
Identification Number/PAN
Country issuing TIN if different from
the country of tax Residence
@to include USA, where the person is a Citizen/Green Card holder of USA. If a person is resident of more than
one country, mention TIN/TRN of each country separately.
Documentary proof of tax Residence should be enclosed.
Self - Certification
I confirm that I am not a specified US person/ other Reportable Person , though
one or more parameters suggest my relation with the United States of
America/Country other than India. Therefore, I am providing the following
document as proof of my tax Residence in India other than US/other country
Signature
Document Proof submitted
Acceptable Documents i.e., Officially Valid Documents(OVDs)
Passport
Election Id Card
PAN Card
Driving License
UIDAI Letter/Aadhaar Card
NREGA Job Card
ALLAHABAD BANK
Customer Declaration
(i)
Under penalty of perjury, I/We certify that:
The applicant is an applicant taxable as a US person under the laws of the United States of America (“US”) or any state or
political subdivision thereof or therein, including the District of Columbia or any other states of the U.S., (ii) an estate the
income of which is subject to U.S. federal income tax regardless of the source thereof. (This clause is not applicable only if the
account holder is identified as a US person)
(ii) The applicant is an person taxable under ………………………………………………………State.
(iii) I/We understand that the Bank is relying on this information for the purpose of determining the status of the applicant named
above in compliance with FATCA/CRA. The Bank is not liable to offer any tax advice on FATCA or its impact on the applicant.
I/We shall seek advice from professional tax advisor for any tax questions.
(iv) I/We agree that as may be required by domestic regulators/tax authorities, the Bank may also be required to report, reportable
details to CBDT or close or suspend my account.
(v) I/We certify that I/We provide the information on this form and to the best of my/our knowledge and belief the certification is
true, correct, and complete including the taxpayer identification number of the applicant.
Signature :
Name :
Date(DD/MM/YYYY) :
I hereby confirm the information provided above is true, accurate and complete.
Subject to applicable local laws, I / We hereby giving consent to Allahabad Bank or any of its affiliates (including
branches) (Collectively “the Bank”) to share my / our information with domestic or overseas regulators or tax
authorities where necessary to establish my tax liability in any jurisdiction.
Where required by domestic or overseas regulators or tax authorities, I consent and agree that the Bank may
withhold from my account(s) such amounts as may be required according to applicable laws, regulations and
directives.
I undertake to notify the Bank within 30 calendar days if there is a change in any information which I/We have
provided to the Bank.
Declaration & Acknowledgment:
I/We declare that the above information in the submitted documents to be true, complete and updated and the
submitted documents are genuine and duly executed.
Date: DD/MM/YYYY
Place:
Signature of the Applicant/Account Holder