OSBI
Bandarugudem Branch - 20514 Date .23/o,/2ozr
CUSTOMER REQUEST FORM
CUSTOMER NAME SRIHARI..GOABOTHULA..
ACCOUNTNUMBER :.325).R.6&6...
MOBILE NUMBER:.9l4.Qy....&3..2.s....
ADDRESS
PRESENT ADDRESS
OLD ADDRESS
H.No. H.No.
Village Cheylle. Village :...
Mandal Manda!
Pincode ...O6.1..2: Pincode ..06.2...
Type of Request : Tick Whichever is Applicable:
1 Convert Non Cheque mode /Cheque book request on above address (Chq Leaves : 25/50/100)
2 Stop Cheque : Cheque No. From : Cheque No. To ..
3. Account Ciosure /Renewal of mySavings / Current/Stdr/Tdr/Rd Al...
andclosure amount credit to A/c
4. Statement of Account:From To:..
5 Account Transfer :New Branch Name Code
6. Account Tye Change: New A/c. Type
7. Change ofName/Address :.
8. Blocking /Unblocking of ATM Card No.:
9. losue of FtESHI REPLACEMENT atsCard. Freda ATM (aso( RSP Gd)
10. Issue of Duplicate / Continuation Passbook.
11. Revalidation /Cancellation of DDs Nos.
Roileay Salers leck AT ad
12. Making A/c. Operative from Inoperative / Dormant Status.
13. SMS Alerts / Change Mobile Number:.
14. Email Id.
15. Standing Instructions to above Savings Alc No. For Transfer into RD/
LoanA/e. No. :.. Amount Rs.... Start Date .. .Freq: M/QrY
16. UID Linking to my SB/CA account, UID No..
17. KYCUpdation tomy SB/CA accountDocuments Enclosde: Aadhar /Voter ID / Nrga Card/ Pan Card /
Driving Licence / Passport.
18. CIF Deduplication (Enclose Copies of Both Pass Books)
From CIF To CIF;
19. Closure of Loan A/c. No. ....Funds transfer from A/c.
Declaration : I here by agree toterms and conditions stipulated by the Bank and also authorize the Bank of
applicable charges from my A/c
Signaturfof the Customer Maker Branch / Service Manager
3TET
Govermment of India
2081/11562/03307
Enrallment No
Bombathula Srihari
2.191B.
MANGAPEIA MANDAL.
Cteupalli
VTC Cherpatle, O
Dstç: Muiuiu.
1086932 Sub D:stnct Maa
State lelangaa,
PING: 561/?
Mobile 9494 'A31/3
KC108569329FL
b egrb ño/Your Aadhaar No:
8843 61108545
Government of India
Bombothula Srihari
S DOB. 27/10/t985
DAN Male
8843 61108545
399029
Adj Adjustment pft Draft Proc = Processing Charge
Amt Amount Dish/dsh = Dishonour rd = Recurring Deposit
Ar Arrear Ret/Rtn Return
bal = Balance irth Rnd Round of
Capn Capitalization Fund Transfer SB = Savings Bank
Chg ch Charge SC Short Credit
Cha Cheque SI/So/SORD = Standing Instruction
Cios Closure S/DWIH/o = Son/DaughterWife/Husbandof
Coli Collection tr/trf/xfer = Transfer
Comm Commnission Telegraphic Transfer
CDR/CORR Correction txn = Transaction
Ing
CR = Credit &Telegram Wd! Withdrawal
Csh = Cash
POntOT Sale +MOD Bal total balance(SB +linked M0D alc)
State Bank of India
INB Mobile Bank Stock No: 1,280
Comp No : 1992805
Savings Bank Account ADALATH ROAD-WARANGAL
CIF NO 86475817591 OPP: DEO OFFICE, DC PLAZA
AccoJ i,i 32590621867
CUSlOmC i amc: MI. SRIHARI BOMBOTHUL,
S/D/W/H/o: SAMMAl AH
Address:H.NO. 1-9- 1019, POSTAL COLONY. Phone:2551531
Enail:
For State Bark of Inda
. .d i i , .NAMKONDA, Branch Code: 13436
Date of Issùe:15/10/ 2012
Phone: 15/10/2012 s53575lBranth ataget
i l 1 0 r Future use) IESC: SRINnOi346
GOVT.OF INDIA
NCOLE TAX DEPARTHEXYT
SAIHARI BOMBOTHULA
SAMMAIAH BOMBOTHULA
27/10/1985
PenntAccount Number
BFIPB1140L
9439283/23
?3390200o3
