Annexure I

STATEMENT OF PERSONAL ASSETS AND LIABILITIES OF SHRI/SMT. - .

To,
The Chief Manager,
Punjab National Bank,
Pedder Road, Mumbai
I/We append below the details of my/our assets and liabilities as on
Liabilities

Assets

Dues to PNB

Cash

Dues to other Banks

Bank Balance

Dues to employer

Deposits

Dues to employer

Capital Investments

Tax Liabilities

Govt. Securities

Other

LIC Surrender Value

Shares/Debentures
Mutual Funds/Bonds
PF accumulated
Balance
PPF Balance, if any
Advance Paid, if any
Immovable Properties
(Proof Attached)
Land
Bldg./Ft./Bungalow etc
Other Assets
Own Vehicle

Total

Gold, Furniture and other

House hold items
Total

I hereby declare & confirm that the information given above is true to the best of my knowledge & belief. I
shall keep the bank informed of any changes in the particulars furnished above.
Date:

Signature:

Name and Address: