IDBI BANK LIMITED

CSC_____________

Statement Of Assets And Liabilities as on _____________

(This form should be obtained from borrower / co-borrower/guarantors)

1 Name of the Borrower/Co-

Borrower/Guarantors
2 Nationality
3 Father's/Husband Name
4 Present Address
5 Permanent Address
6 Telephone No
7 Mobile No
8 Date Of Birth
9 Occupation Service/Business/Others(Specify)

10 If in Service Name of the employer

Address/Tel No
Service Since
Post held
11 If in Business Name of the Firm
Address/Tel No
Established Since
Line of Activity
Experience
Position
12 Annual Income (As per ITR
dated ---/---/----)
13 PAN No

14. Bank Account Details

(Rs. in Lakh)
Bank Branch SB/CA/CC/OD Present Balance(As Avg Bal in last 6
A/c No. on ----------------) months

15. DETAILS OF ASSETS

A. IMMOVABLE PROPERTY (Amt. in Lakh)

Assets Own / Area Free Location/ Purchase Present Whether

Joint (Sq hold or address Cost Value encumbered
name Ft) Lease (Give details)
hold
Non Agri. Land
i. Commercial

ii. Residential

Flat / House
 2 Networth Statement

Agri. Land

Others

Whether Self occupied / Rented / Leased out (Give details) :

______________________________________________

B. MOVABLE PROPERTY :

(i). Term Deposits: (Amt. in Lakh)

Deposit Bank/Branch Name Amount & Date of Maturity date Maturity amount
Receipt No. Receipt

(ii). Investment in Govt. securities like Bonds / PPF/ NSC / KVP / IVP etc. (Amt. in Lakh)
Nature of Certificate Dt. of Issuing Office/ Face value Due date Maturity amount
Securities. No purchase Post office

(iii) Insurance Policies (Amt. In Lakh)

Name of Company & Policy No Dt. of Sum Surrender Annual Premium paid
issue assured value premium upto what period

(iv) Shares / Debentures / Mutual Fund etc. (copy of Demat Statement to be enclosed) (Amt. in Lakh)
Name of No. of Certificate No./ A/c No./ If charged/ Current Market value
Company shares/ Demat Account No. pledged, the
nature and extent
of charge/ pledge

(v). Vehicles : (Amt. in Lakh)

Type of Registration Model Year of make Cost at the time RC Book Present value
Vehicle No. of Purchase details

(vi). Other Movables (Amt. in Lakh)

Description Quantity Valuation (approx)*

(* attach Valuation certificate, if available)

(vii) Other Investment in business

Name of the Firm Amount of Investment As per Balance Sheet dated (--/---/----/)
 3 Networth Statement

16. Details of Liabilities

i. As Borrower :
(Amt. in Thousands)
Name of the Purpose of Amt. of Loan Security Repayment Terms Outstanding Balance
Bank Loan (As on --/---/----/)

ii. As Guarantor : (Amt.in Thousands)

Name of the person/ Name of the Bank / Guarantee Present Status of Outstanding Balance
company to whom Financial Institution Amount (Rs.) Account (As on --/---/----/)
Guaranteed (Performing/NPA)

To the best of my/our knowledge I/we hereby declare that above statement given by me/us are correct

Place .................................
_________________________________
Date ................................. Signature (Borrower/Guarantor)

NetWorth* assessed as per market report and the details In case of Guarantor, Signature verified
provided by the Borrower, Rs. _________ (by the Borrower)
(Bank Official)
Verified the documents (with the original) by ........................
________________
_________________ __
Date : .................. Signature & Code
Borrower’s Signature
Date : .................

Enclosure (in support of above declarations):

i. Balance Sheet, Profit & Loss Account, Trading Account, Capital Account (Audited / Unaudited)
ii. Copy of Employment Certificate with details of salary drawn.
iii. Copies of Agreement / revenue records / Tax paid receipt/society certificate in respect of
land/building/flat owned by me.
iv. Copies of Income Tax / Wealth Tax Returns / PAN Card / Assessment Order along with proof of
payment.
v. Other relevant documents.

Certified by CA. _____________________

(for cases having overall exposure above Rs.1 crore)
Date:
Place:
 4 Networth Statement

Calculation of Networth

A. Individuals and proprietory concerns

a) Moveable assets like Bank Deposits, Gold ornaments, jewellery, investment in shares, debentures,
company deposits.
b) Personal unencumbered immovable properties like self acquired property, share in the ancestral
property acquired on division of Joint Hindu Family as per Hindu Succession Act / Indian
Succession Act.
c) Capital investment in the business including Investment in partnership.
d) Out of the above properties / assets i.e. (a) to (c), existing borrowings, if any, should be reduced to
arrive at the net value of assets. This net value of the assets shall be the net estimated worth or
means of the borrower.

B. Partnership & Joint Hindu Family (HUF) concerns

a) Capital invested in the business by all the partners
b) Undivided profits
c) Total worth of individual partners i.e. total value of liquid assets of the partners; total value of self
acquired immovable properties of each partner; investment; stock; cash deposits, etc., stake in
sister concerns.
d) Out of the above items, i.e. (a) to (c) deduct borrowings, accumulated losses, intangible assets, if
any
e) However, while computing the liquid assets of the partner the value of shares in the Private /
Public Limited companies, held by partners, proprietor, etc., of these firms should not be included
at the face value, if the scrip is not quoted in the stock exchange and / or is not readily marketable.
The full face value of shares can be taken into account in assessing the holders’ means only if the
companies whose capital these shares represent are first rate running concerns, which have been
continuously making good profits in the past and whose existing liabilities do not our-weigh their
easily realizable assets.
f) Further while assessing the worth of a partner, his investments should be ignored, as the
investment in such firm is included in the firm.

C. Limited Companies
a) Apart from paid capital and free reserves as appearing in the balance sheet, balance in the share
premium account, capital and debenture redemption reserves, and any other reserves (not being the
reserve created for repayment of any future liability for depreciation in assets, for bad debts or
reserves created by revaluation of assets) shall also be taken into account.
b) Accumulated balance of loss, balance of deferred revenue expenditure and other intangible assets
should be deducted from the capital as in (a) above.