THE KALYAN JANATA SAHAKARI BANK LTD.

(SCHEDULED BANK) STATEMENT OF ASSETS AND LIABILITIES (To be obtained from Borrower/Guarantor) Date: Name of the Account : Name of the Borrower/Guarantor: (to whom the statement belongs) ASSETS: Sr. Description No. (Rs. in lakh) Present Market Value (Approx.)

Immovable Properties: Sr. Description of Location/Address Date of Original No. Property(i.e. Agri. land/ Purchase purchase NA plot/flat/house/gala cost etc. with area) 1 2 3 Total A Movable Assets: Sr. Details of Assets(Furniture and fixtures, equipment, consumer durables, No. vehicles, gold and jewellery, other valuables etc.) 1 2 3 Total B Investment in Business: Sr. Name of the company/firm/concern in which investment is Amount No. made(As capital, loan, quasi equity, deposit etc.) invested 1 2 3 Total C Deposits held with Bank/s: Sr. Name of the Bank Type of Amount No. Deposit 1 2 3 Total D Life Insurance Policies: Date Policy No. Annual Sum Date of Dt.of last Surrender of Premium Assured maturity premium Value Policy paid

Total

E P.T.O.

Sr. Description No.

Present Market Value (Approx.)

Government Securities. NSC, Units of UTI, Shares/Deposits of listed companies etc.: Sr. Description Face Value/ No Purchase value 1 2 3 Total F Rs. X (Rs. in lakh) Details of securities furnished Limit/Outstanding Bal.

Total Assets A+B+C+D+E+F

LIABILITIES: 1 From Banks/Financial Institutions: Name of the Nature of Purpose Institution/Bank Credit facility

Total From Others: Name of the Lender

G Details of Securities furnished Amount Borrowed

Total Other Liabilities(Please Specify):

Total Total Liabilities G+H+I Net Worth X-Y Rs. Rs. Y

INDIRECT LIABILITIES: Details of Guarantee Obligations: Name of the Party for whom Extent to which guarantee is guarantee is furnished furnished Rs.

(Rs. in lakh) Name of the Bank/Institution/ Creditor

I certify that the information contained in the above statement is true and correct. Signature: Name: Address: Note: 1. Please attach a separate sheet if the space provided in the statement is not adequate. 2. Date furnished above should be supported by copies of documents conferring/evidencing the title and ownership such as title deeds, tax receipts, deposit receipts, bank pass book/statement, certificates, insurance policies, wealth tax/income tax returns etc.
(File:Process Notes/Assets and Liabilities Statement)