APPLICATION FORM FOR LOAN AGAINST SECURITY OF GOLD ORNAMENTS/ COINS

Applicant details

Name
Current Residence
Contact Details Phone Number Mobile Number
Permanent Residence
Office Address
Office Phone Number
Address for Correspondence Office Residence
Phone number for communication Office Residence Mobile
Gender Male Female
Date of Birth
PAN number
Religion Hindu Muslim Sikh Christian others
Occupation Salaried Profession Business others
Category SC ST OBC Minority others
If farmer, Please tick the Marginal Farmer Small Farmer Agricultural Labourers
appropriate category
Existing relationships with the Bank Bank Accounts Credit Cards Loans Please furnish CIF No.

Details of other loans

Bank/ Branch Loan Amount (O/ S) Tenure Monthly Installment Loan Type

Bank/ Branch Loan Amount (O/ S) Tenure Monthly Installment Loan Type

Detail terms of the Gold Loan and other charges

Nature of the credit facility

Loan against pledge of gold ornaments/ coins
Total amount of Gold Loan requested for ` (Rupees only)
Interest % per annum is compounded with Monthly Quarterly Half Yearly Yearly rests. The other applicable charges, taxes or other
statutory levies, if any, shall be paid separately. The ROI may be decided by the bank from time to time at its sole discretion (the “Applicable Rates”).

Payment of interest and other charges

Monthly Quarterly Half yearly Yearly

Other charges
Non-refundable processing charges* ` (plus applicable taxes or other statutory levies, if any)

* The one-time non-refundable processing fee is collected by the Bank for the purpose of appraising the application of the Applicant for the Gold Loan and the same is
independent of the subsequent disbursement of the Gold Loan by the Bank. Please note that the processing fee is payable at the time of submitting this Application
Form through such mode as may be acceptable to the Bank including debiting the processing fee amount from the disbursal amount.

Repayment of the gold loan

The tenor of the Gold loan is ____ months . Repayment date subject to terms and conditions applicable to the Gold Loan. Penal/
default interest: % p.a. additional, (plus applicable taxes or other statutory levies, if any). Security offered/ proposed to be handed over to the
Bank: Gold Ornaments/coins as described under the Inventory cum Appraiser Certificate annexed hereto. Margin of the Security required to be placed with
the Bank: % of the current price of the Gold Ornament as determined by the Bank through its relevant sources/ appraiser.

Source Details
FOR OFFICE USE ONLY

GL SM Code SE Code IVBL Code

Channel Details
Campaign Direct Sales DSA Direct Walk-in Others

ING VYSYA BANK LIMITED, Regd. and Corporate Office ING VYSYA HOUSE, #22, M.G. Road, Bangalore - 560 001. www.ingvysyabank.com 1
 Schedule of Gold Ornaments/ coins pledged:
Description of Gold Ornaments/ Coins:
No. of Gold Ornaments/ Coins:
Gross Weight (Grams):
Net Weight:
Rate per Gram: ` as on

Declaration

I/ We hereby request ING Vysya Bank Limited ('the Bank') to grant me/ us a loan of ` ____________ for a period of months __ ('Gold Loan') against security/
pledge of gold ornaments/ coins mentioned in the Schedule hereto ('Gold Ornaments/coins') with market value of ` ____________ as on date .The Gold
Ornaments/ coins exclusively belong to me and are acquired by me/ us from my/our legitimate source of income . I undertake to utilize the amount for the
purpose for which it is availed. I hereby declare and confirm that I have read/ been translated (if borrower is not conversant with English language) and
understood the terms of the Gold Loan contained in this Application Form including the Standard Terms and Conditions annexed hereto, copies of which is
provided to me/us and agree to abide by them. I agree to pay interest, service or other charges as may be fixed by the Bank from time to time. All the informa-
tion and particulars furnished by me/ us in this Application Form and other related documents are accurate, up-to-date and complete in all respect and I/we
have not suppressed or withheld any information whatsoever. All details and information, including the Gold Loan terms such as interest rate, prepayment
charges. etc. have been duly filled in without any blanks prior to my/our submission of the Application Form to the Bank. The Bank at its sole and absolute
discretion, may reject this application and not sanction/disburse the Gold Loan and the Bank shall not be responsible/liable in any manner whatsoever to
me/us for such rejection or any delay in notifying me/us of such rejection and any costs, losses, damages or expenses, or other consequences, caused by reason
of such rejection/non-disbursement or any delay in notifying me/us of such rejection/non-disbursement. This Application Form has been duly and validly
executed by me and when accepted/acted upon by the Bank, the Gold Loan terms contained in this Application Form along with all annexures, schedules
including the Standard terms and Conditions annexed hereto would constitute legal and valid obligations that are binding on and enforceable against me/us
and I/ we will be bound by the amended terms & conditions. I/ we confirm that the initials on this Application Form are made by me/us and the validity of
such initials shall not be disputed by me/us. I/we acknowledge that the Bank reserves the right to retain the photographs and documents submitted with this
Application Form and may not return the same to me/us.
I/we consent/ do not consent to receive information/ services, etc. for marketing purposes through Telephone/Mobile/SMS/Emails by the Bank/its agent.
I/we am/ are aware that post registration, I/we may receive a call from the Bank to verify the correctness of the request for registration. I/we authorize the
Bank to disclose from time to time any information relating to Gold Loan against Gold Ornament relationship to any parent, subsidiary, affiliate and associate
of the Bank, and to third parties engaged by the Bank, for the purpose of such as marketing of services.

Signature/ LTI of Borrower

2
Terms and Conditions

In consideration of the Bank granting the Gold Loan, I/ we have pledged with you the Gold Ornaments/coins as detailed herein, as security for repayment of the
Gold Loan and agree to abide by the following standard terms and conditions in addition to those stated in the Application Form
1. The Gold Loan shall be repaid by me/us with interest per annum compounded with monthly/ quarterly/ half yearly/ yearly rests as specified in the Application
Form or at such other rate as may be decided by the Bank from time to time at its sole discretion. In the event of a default or delay in repayment, whether of
the principal or interest, I/We shall pay additional penal interest as per the Gold Loan terms in the Application Form as per the Bank's norms from time to time
above the rate of interest charged (as contracted in the Application Form) and other debits (if any) to the loan account/s from time to time compounded
monthly/quarterly / half yearly from the due date of payment or date/s of default or from the date of demand by the Bank, whichever is earlier, till payment
is made in full. I/we authorize you to debit/ credit my account with the Bank towards any charges /amounts towards servicing of the Gold Loan, interest and
other charges. I/We shall utilize the Gold Loan solely for the purpose stated in the Application Form and the Gold Loan proceeds will not be used for any other
purpose including speculative or anti-social purpose.
2. I/We am/are the owner/joint-owners and am/are in possession of the Gold Ornament. My/our title to the Gold Ornaments/coins deposited/ to be deposited
by me/us as security is neither defective/ challenged by any person in any manner nor is it spurious or of inferior quality as it has been acquired by me/us from
genuine sources. No other person has any claim lien or charge over the Gold Ornament. I/We create a first and exclusive charge by way of pledge in favour
of the Bank over the Gold Ornament by depositing it with the Bank in a sealed packet to be kept with the Bank during the tenure of the Gold Loan. I/We agree
that the Bank shall be entitled to open such sealed packet during the tenure of the Gold Loan and conduct an investigation in connection with the quality of
Gold Loan at my/our cost at any time, without notice to me/us. The Gold Ornaments/coins pledged with the Bank shall be kept at my/ our risk in the ordinary
safes of the Bank and I/we agree that the Bank is exercising only the ordinary care of the safe custody. The Bank shall not be liable in case of any damage to
or loss of the Gold Ornament, in whole or partly, by reason of accident, force majeure, act of God, etc.
3. The valuation of the Gold Ornaments/coins shall be done by a gold appraiser appointed by the Bank and the Gold Loan limit shall be determined by the Bank
on the basis of the value of the Gold Ornament as set out in the inventory cum appraiser certificate submitted by the appraiser. The value of the Gold
Ornament shall be subject to the market price of the Gold Ornament from time to time. The value of the Gold Ornament as determined by the appraiser
appointed by the Bank and set out in such inventory cum appraiser certificate including the market rate determined by the Bank from time to time, is accept-
able, final and binding on me/us. The Bank is entitled to reappraise at my/our cost (including incidental charges in connection with reappraisal) the Gold
Ornament, at its sole and absolute discretion, any time during the tenure of the Gold Loan without my/our consent, presence in person, and/ or any prior
notice, through its appraiser. I/we shall be solely responsible for any defects /deficiencies noticed during such re-appraisal by the Bank, and hereby agree to
abide by the decision of the Bank in this regard.
4. I/We shall pay all costs, charges and expenses including stamp duty and legal costs and other charges and expenses which may be incurred in preparation of
any documents related and/or incidental to the Gold Loan including any other additional document as may be required by the Bank from time to time to
secure its rights as a creditor, as also for the enforcement or attempted enforcement of the security, i.e. Gold Ornaments/coins.
5. The Gold Loan shall be repaid promptly as per the repayment terms contained in the Application Form or as prescribed by the Bank from time to time. Notwith-
standing the repayment schedule, the Bank may, without assigning any reason and upon written notice mailed or delivered to me/us, cancel in full or in part
the Gold Loan and demand repayment thereof with interest and other charges. Upon such notice, the outstanding dues under the Gold Loan shall become
forthwith due and payable by me/us to the Bank. Further, the Bank may also recall the Gold Loan at any time in case of the failure on my / our part to repay
the Gold Loan and / or interest or failure by any other person/s for whom I / we stand as guarantor/surety/co-obligor/s.
6. The following shall constitute an event of default (“Event of Default”) , upon the occurrence of which the outstanding amount under the Gold Loan shall
become immediately due and payable by me/us to the Bank and further enable the Bank to enforce the Gold Ornaments/coins and any other security
furnished hereunder and sell the same, without prejudice to other rights and remedies available to the Bank : a) Breach or failure on my/our part to perform
any of my/our obligations, terms and conditions herein or under the sanction letter or if any circumstance or event occurs which adversely affects my/our
capacity to repay the Gold Loan or any part thereof or perform any of my/our obligations. b) Any of the representations or statements or particulars made/
provided by me/us in the Application Form or herein are found to be false, misleading or incorrect. c) The Gold Loan is not repaid on the due date for payment
of installments/interest or on the date of maturity as per the terms of sanction or upon demand made by the Bank. d) Detection of any systemic fraud in
relation to the quality of the pledged Gold Ornaments/coins or its valuation. e) The value of the Gold Ornaments/coins falls lower than the required margin
of the Bank as applicable from time to time, due to change in market price (whether actual or reasonably anticipated) or any other reason, or if there is any
deterioration or impairment of the Gold Ornaments/coins or any part thereof, which causes the security in the judgment of the Bank to become unsatisfactory
in character or value. f) It is found by the Bank that there is any collusion between the appraiser and me/us resulting in a fraudulent and/or erroneous
valuation of the Gold Ornaments/coins, or in case the Bank has suspicion in this regard. g) Any attachment, distress, execution or other process against me/us
or any of the security is enforced or levied upon. h) Death, insolvency, failure in my/ our business, commission of an act of bankruptcy by me/us, or I/we
am/are declared as willful defaulter. i) An attempt by me/us to create or creating any charge, lien, any other encumbrance over the pledged Gold
Ornaments/coins. j) One or more events, conditions or circumstances, including any change in law, occur or exist which in the sole opinion of the Bank could
have a materially adverse effect on the repayment by me/us or recovery by the Bank of the Gold Loan. I/we shall promptly notify the Bank in writing upon
becoming aware of any Event of Default or other condition which would be likely to constitute an Event of Default.

Signature/ LTI of Borrower

3
 7. The Bank is entitled to hold the Gold Ornaments/coins as security for repayment of the Gold Loan and for any additional loan sanction or on renewal of
the Gold Loan, at the Bank's sole discretion and appropriate the same for the repayment /liquidation of such loan along with interest and other charges
and also towards any other liability/ies payable by me/us in respect of any advance/financial assistance granted/to be granted hereafter to me/us and/or
owing/ that may be owing by me/us hereafter to the Bank at any office of the Bank on any account whatsoever whether solely or jointly with others and
whether as principal debtor or surety or guarantor. The Bank is hereby authorised by me/us without any precondition on the happening of any Event of
Default to enforce the Gold Ornaments/coins and any other security by disposing it, without any notice to me / us, either by a public auction or a private
sale, and appropriate the sale proceeds towards the outstanding dues in the Gold Loan with up to date interest payable thereon and other charges, or any
other loan or liability I/ we have or may have in future towards the Bank, and shortfall, if any, after adjustment of the net sale proceeds, shall be repaid
by me / us forthwith on demand by the Bank. The balance, if any, of sale proceeds, after appropriation of my / our dues and expenses of sale, may be held
by you in my / our account with you or may be sent to me / us by way of Demand Draft /Pay Order or any other mode, at my / our cost. I/we shall pay the
expenses incurred by the Bank in connection with auctioning / sales of the Gold Ornaments/coins, whether fully or partly, to realise the dues in the Gold
Loan including the charges incurred for advertisement in papers and other incidental expenses in this regard.
8. The decision and action of the Bank with regard to sale of Gold Ornament is binding on me/us and I/we will not make any challenge, make any claim or
objection as to the regularity of the sale of Gold Ornaments/coins or any decision by the Bank in that respect, and confirm that I/we am/are not entitled
to any damage against the Bank on the ground of irregularity of the sale.
9. The rights of the Bank under these additional terms and conditions shall in no way affect the Bank's right to general lien/ set off as available to the Bank
under the provisions of law. In addition to any general lien or similar right to which the Bank as bankers may be entitled by law, the Bank may, at any time
and without notice to me/us, combine or consolidate all or any of my/our accounts with any liabilities to the Bank and set off or transfer any sum or sums
standing to the credit of any one or more of such accounts in or towards satisfaction of any of my/our liabilities to the Bank on any other account or in
any other respect, whether such liabilities be actual or contingent, primary or collateral, and several or joint. In the event of my / our requiring the Bank
to advance any loan and / or financial facility/ies at any time hereafter and the Bank granting such loans and/or facilities for whatever purpose, these
additional terms and conditions should be treated and should serve as sufficient document for that purpose, unless the Bank requires execution of
additional documents to its satisfaction, prior to or after such loan or facility is granted.
10. If, in the opinion of the Bank, the market value of the Gold Ornaments/coins is depreciated from its original appraised value, I/we shall immediately on
receipt of notice from the Bank either provide additional Gold Ornaments/coins/ any other security as demanded by and acceptable to the Bank for the
deficit value or pay a sufficient amount to reduce the amount outstanding in the loan account as required by the Bank along with applicable charges. I/
we acknowledge and agree with the rate per gram fixed by the Bank for Gold Loan as on date of the inventory cum appraisal certificate issued by the
appraiser as annexed hereto, and in case of downward fluctuations of price or upward movement of rate of interest, the Bank may demand (partial)
repayment to maintain a sufficient margin or seek additional Gold Ornaments/coins on one week's notice.
11. I/We confirm having received, read and understood the terms and conditions applicable to this Gold Loan in the Application Form including these standard
terms and conditions and accept them hereby, without notice, unconditionally, I/ we agree that such terms and conditions may be changed by the Bank
at any time and I/we will also be bound by such amended terms and conditions
12. The Bank shall have the right to disclose information relating to me/us to the Credit Information Bureau of India (CIBIL) and/or any other
governmental/regulatory/statutory or private agency as required under law form time to time. I/We hereby authorize and give consent to the Bank to
disclose, without notice to me/us, information furnished by me/us in the Application Form(s)/related documents executed/to be executed in relation to the
facilities availed from the Bank, to the Bank's other branches/ subsidiaries/ affiliates/ credit bureau/ rating agencies, service providers, banks/financial
institutions, governmental/regulatory authorities or third parties for KYC information verification, credit risk analysis, or for other related purposes that the
Bank may deem fit. I/We waive the privilege of privacy and privity of contract.
13. I/We agree and declare that Bank shall be entitled to assign or transfer or securitise the Bank's rights and obligations arising hereof without any prior
notice, to any other bank(s)/ person/ company/partnership firm/agency/financial institutions of Bank's choice in whole or part, as the Bank may decide.
I/we agree that any such assignment or transfer or securitisation shall be conclusively binding on me/us. I/we shall not assign or transfer all or any right,
benefit or obligation herein, without the prior written approval of the Bank.
14. At the time of renewal of the Gold Loan, whether during or after the expiry of the tenure of the Gold Loan, I/we may request the Bank to grant the renewal
to me/us on a higher/lower Gold Loan to value ratio or any other term which the Bank may allow at its sole and absolute discretion subject to payment of
a fee as the Bank may prescribed
I/We hereby confirm that the official of the Bank has read and translated accurately the aforesaid standard terms and conditions, Application Form and
declarations in my/our vernacular language and I/we have completely understood the same.

Signature/ LTI of Borrower

4
Pronote (DPN) for fixed rate of interest

` Place Date
On Demand I/ We
Individually/ Jointly/ Severally Promise to pay ING Vysya Bank Limited or order, the sum
of Rupees
Only For value received with interest: from this date at percent per Annum compounded with annually/ half yearly/
quarterly / monthly rests.

Name of the signatory

Address Revenue stamp to be
affixed with
signature of Borrower

Take delivery letter (TDL)

(From)

Place
Date
TO:
The Manager
ING Vysya Bank Limited
Branch

Dear Sir,
Please take delivery of the accompanying On Demand Promissory Note (DPN) dated for
` (Rupees )
duly executed by me/ us in your favour for which consideration has been fully received by me/ us, partly received by me/ us now and partly
shall be in stages.
I/ We jointly and severally agree that the said DPN shall be a continuing security for the amount disbursed or to be disbursed along with
interest thereon from time to time which shall be due to the Bank in stages either through my/ our operative account in the name of
me/ us, the said account is not to be considered closed for the purpose of this security and the security is not to be considered exhausted by
reason of the said account being brought to credit at any time or from time to time and the payments so made shall be binding on me/ us
without prejudice to Bank's right to demand repayment of the entire loan from me/ any one of us at any time.
I/ We jointly and severally further agree that the said DPN shall also be a continuing security for any balances due to the Bank from time to
time in my/ our said account and for the ultimate balance and interest remaining unpaid in the said account and/ or any other balance due
from me/ us to the Bank under any arrangement, by whatever name called. I/ We shall remain liable under the said DPN not withstanding the
fact that by payments made into the account, the balance in the said account may, from time to time, be reduced or overdrawn or even that
the balance of the said account may be in credit in the course of normal operation or otherwise.

Signature/ LTI of Borrower

5
6
Sanction letter Bank Copy

Date:

To,
Borrower Name:
Address:

Gold Loan of a sum of ` (in words Indian Rupees

) is granted to Sri/ Smt at % per annum and repayable
on or before

Foreclosure charges: If the loan is closed before 1 & 3 months from the date of Disbursement the following Foreclosure charges will be applicable:

If Closed Before Foreclosure Charges

1 Month
3 Months

Interest Repayment:
Monthly : Repayment date of every month

Quarterly : Repayment dates 1. 2. 3. 4.

Half Yearly : Repayment dates 1. 2.

Final interest payment date with principle amount:

Date:
Signature of Bank Official

I confirm that the Gold Ornaments/coins described in the Application Form dated more fully detailed in the Inventory cum
Appraiser Certificate dated annexed hereto, have been appraised by the appraiser at branch premises in my presence.
The sanction and the Gold Loan are subject to the terms and conditions in the Application Form and the standard terms and conditions annexed thereto.

Accepted as per above T&C

Customer Name and Signature

Declaration
I have read and understood the standard terms and conditions of loan against gold ornaments / coins and I will abide by the same.

Borrower Name and Signature

Acknowledgement by bank official

I acknowledge the receipt of Gold Ornaments/ coins as described in the Application Form dated__________________and the Inventory cum Appraiser
Certificate dated______________ weighing ___________ grams (gross weight) pledged by with us towards Gold Loan.
Account No.
Date
Signature of Bank Official

7
8
Sanction letter Customer Copy

Date:

To,
Borrower Name:
Address:

Gold Loan of a sum of ` (in words Indian Rupees

) is granted to Sri/ Smt at % per annum and repayable
on or before

Foreclosure charges: If the loan is closed before 1 & 3 months from the date of Disbursement the following Foreclosure charges will be applicable:

If Closed Before Foreclosure Charges

1 Month
3 Months

Interest Repayment:
Monthly : Repayment date of every month

Quarterly : Repayment dates 1. 2. 3. 4.

Half Yearly : Repayment dates 1. 2.

Final interest payment date with principle amount:

Date:
Signature of Bank Official

I confirm that the Gold Ornaments/coins described in the Application Form dated more fully detailed in the Inventory cum
Appraiser Certificate dated annexed hereto, have been appraised by the appraiser at branch premises in my presence.
The sanction and the Gold Loan are subject to the terms and conditions in the Application Form and the standard terms and conditions annexed thereto.

Accepted as per above T&C

Customer Name and Signature

Declaration
I have read and understood the standard terms and conditions of loan against gold ornaments / coins and I will abide by the same.

Borrower Name and Signature

Acknowledgement by bank official

I acknowledge the receipt of Gold Ornaments/ coins as described in the Application Form dated__________________and the Inventory cum Appraiser
Certificate dated_____________ weighing ____________ grams (gross weight) pledged by with us towards Gold Loan.
Account No.
Date
Signature of Bank Official

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 To be retained by the branch
Declaration of Purpose of Loans (Please tick whichever is applicable and fill the declaration applicable under product norm)

I furnish the following particulars in regards to the application form dated pertaining to the Gold Loan with security of
Gold Ornaments/ Coins.
Product Code 4202
For Agricultural Purpose
1. Occupation: Farmer Tenant Farmer ShareCropper Landless Others (Pls Specify)
2. Extent of Land Holdings (in acres) 3. Location of the Land / Survey No.
4. Agri Purpose of the Gold Loan
For Allied agricultural activities
1. Occupation: Dairy Fishery Bee Keeping Piggery Others (Pls Specify)
2. No of Value of existing cattle (if any)
3. Allied agri purpose of the Gold Loan
I hereby represent, declare and confirm that the Gold Loan proceeds will be used by me/us solely for the purpose of agriculture, as per the above details.
Product Code 4203
PSA
Small Business/ Retail Trade/ Other Micro and small enterprises Purpose
I hereby represent, declare and confirm that the Gold Loan proceeds will be used by me/ us solely for the purpose of
Working Capital Fixed asset Purchase Both; in my small business/ retail trade/ SME named
Other PSA
Sub Sector Code
I hereby represent, declare and confirm that the Gold Loan proceeds will be used by me/us solely for the purpose of Signature/ LTI of Borrower
Children Education Housing Repairs Margin for Home Loans Others (Pls specify)
Non PSA - General Gold Loans against Gold Ornaments / Coins
I hereby represent, declare and confirm that the Gold Loan proceeds will not be used by me/us for any illegal or speculative purposes
I am aware that its on the faith of this representation, declaration and confirmation that the bank agreed to consider my application form
dated for grant of Gold Loans.

To be retained by the branch

Declaration of Purpose of Loans (Please tick whichever is applicable and fill the declaration applicable under product norm)

I furnish the following particulars in regards to the application form dated pertaining to the Gold Loan with security of
Gold Ornaments/ Coins.
Product Code 4202
For Agricultural Purpose
1. Occupation: Farmer Tenant Farmer ShareCropper Landless Others (Pls Specify)
2. Extent of Land Holdings (in acres) 3. Location of the Land / Survey No.
4. Agri Purpose of the Gold Loan
For Allied agricultural activities
1. Occupation: Dairy Fishery Bee Keeping Piggery Others (Pls Specify)
2. No of Value of existing cattle (if any)
3. Allied agri purpose of the Gold Loan
I hereby represent, declare and confirm that the Gold Loan proceeds will be used by me/us solely for the purpose of agriculture, as per the above details.
Product Code 4203
PSA
Small Business/ Retail Trade/ Other Micro and small enterprises Purpose
I hereby represent, declare and confirm that the Gold Loan proceeds will be used by me/ us solely for the purpose of
Working Capital Fixed asset Purchase Both; in my small business/ retail trade/ SME named
Other PSA
Sub Sector Code
I hereby represent, declare and confirm that the Gold Loan proceeds will be used by me/us solely for the purpose of Signature/ LTI of Borrower
Children Education Housing Repairs Margin for Home Loans Others (Pls specify)
Non PSA - General Gold Loans against Gold Ornaments / Coins
I hereby represent, declare and confirm that the Gold Loan proceeds will not be used by me/us for any illegal or speculative purposes
I am aware that its on the faith of this representation, declaration and confirmation that the bank agreed to consider my application form
dated for grant of Gold Loans.
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 Acknowledgment from the Borrower/s (while redeeming the Gold Ornaments/ coins)
I/ We hereby acknowledge the receipt of all the Gold Ornaments/ coins specified in the Application Form dated and more
fully described in the Inventory cum Appraiser Certificate dated and confirm that it/ they is/ are intact and in the condition
as it/ they was/ were when the Gold Ornament/s has/ve been given as a security by me/ us for the Gold Loan extended to me/ us by ING Vysya Bank
_____________ branch ('the Bank').

Date Signature verified

Signature/ LTI of Borrower

Declaration
I/ we confirm that
• I/ we have received the “Acknowledgement” from the Bank's official and note to produce the same at the time of closing the Gold Loan/ redeeming
the Gold Ornaments/ coins.
• The Gold Ornaments/ coins described in the Inventory cum Appraiser Certificate (of which copy was received by me/ us) were appraised by the
appraiser of the Bank in my/ our presence and I/ we accept the appraised value of the Gold Ornaments/ coins by him.
I/We also further confirm that no precious stones are embedded to the Gold Ornaments/ coins. The contents of the Demand Promissory Note (DPN)
and the above document executed by me/ us on , have been explained to me/ us in a language understandable to me/ us by
Sri/ Smt , who is well known to me/ us.
If the execution is by illiterate, the left thumb impression (LTI) or right thumb impression (RTI) is affixed.
Date Place
Name of the translator Signature/ LTI/ RTI of Borrower/s

Address
Language in which the contents of the documents were explained to the borrower/s
Date Place Signature of the Translator

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 Inventory Cum Appraiser Certificate
Bank copy

Name of the Borrower CIF No. A/c No.

Sl. Ornament/ Coin Gross Net Estimated Pure Weight Rate/Gram Value of Jewel Remarks
No. Description Weight Weight Purity to 22 Carat (Appraiser (Pure Wt. X (Breakage/)
(In Grams) (In Grams) (in Carat) (Net Wt XMF*1) Quote) Rate/Gram) stone Details

Grand Total

*1: Multiplication Factor (MF) for, 18 Ct - 0.818, 19 Ct - 0.864, 20Ct - 0.909, 21Ct - 0.955, 22Ct - 1.00, 23Ct -1.045, 24Ct -1.091, Gold Ornaments/ Coins less than 20 Carat & Gold Coins less than 22 carat is not
permitted to pledge
I hereby declare & certify that the,
a). aforesaid ornaments/coins are tested by me using appropriate tests in all respects & recorded the value
b). aforesaid ornaments/coins are pure and made up of sovereign touch genuine gold.
c). aforesaid ornaments/coins are of the Gross weight, Net weight, Pure weight & appraised value as recorded above, & I guarantee the above valuation.

Date
Borrower Name and Signature Appraiser name & signature with seal

13
14
 Customer copy Inventory Cum Appraiser Certificate

Name of the Borrower CIF No. A/c No.

Sl. Ornament/ Coin Gross Net Estimated Pure Weight Rate/Gram Value of Jewel Remarks
No. Description Weight Weight Purity to 22 Carat (Appraiser (Pure Wt. X (Breakage/)
(In Grams) (In Grams) (in Carat) (Net Wt XMF*1) Quote) Rate/Gram) stone Details

Grand Total

*1: Multiplication Factor (MF) for, 18 Ct - 0.818, 19 Ct - 0.864, 20Ct - 0.909, 21Ct - 0.955, 22Ct - 1.00, 23Ct -1.045, 24Ct -1.091, Gold Ornaments/ Coins less than 20 Carat & Gold Coins less than 22 carat is not
permitted to pledge
I hereby declare & certify that the,
a). aforesaid ornaments/coins are tested by me using appropriate tests in all respects & recorded the value
b). aforesaid ornaments/coins are pure and made up of sovereign touch genuine gold.
c). aforesaid ornaments/coins are of the Gross weight, Net weight, Pure weight & appraised value as recorded above, & I guarantee the above valuation.

Date
Borrower Name and Signature Appraiser name & signature with seal

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