FORM A

[See clause (d) of rule 2 and sub-rule (1) of rule 3]

Serial No. ................
Application for opening of an account under Senior
Citizens Savings Scheme, 2004
To
Paste here a copy of
The Postmaster/Incharge recent
..................................................... (name of the deposit office) photograph.

...................................................
(Joint Photograph of
................................................... both the Depositor &
Spouse in case of a
joint account).

*Name of Agent (in case of the account introduced through agent) ...................................................................
Agency Code No. ................dated...........................................valid up to..........................................................

PAN No. (of applicant).............**.

Sir,
1. I, ......................................................, son/daughter/wife of.................................................................., a permanent
resident of ..................................................................................................., aged .......... years, hereby apply for opening
of an account under the Senior Citizens Savings Scheme, 2004 (hereinafter referred to as the said scheme), in my
name/jointly in my name and my spouse .................................. (name and address of spouse with age)* and tender
herewith Rs. .......................... (Rupees .................................................. ) in cash/cheque/demand draft, the particulars
of which are filled in the enclosed ‘pay-in-slip’ (Form D), towards deposit in the account.
2. I/we* hereby declare that,—
(i) I/we* have clearly understood the Senior Citizens Savings Scheme Rules, 2004 governing the accounts under
the said scheme, as amended from time to time (hereinafter referred to as the said rules);
(ii) I/we* shall abide by the said rules in letter and spirit;
(iii) the details of other accounts opened earlier by me/us* under the said scheme, are as under :—

Sl. No. Name of depositor(s) & Type of Name and Address of the Account No. with date of Amount of
account (Individual/Joint) Deposit office opening Deposit
1.
2.
3.
(iv) I/we* shall adhere to the ceiling on deposits, taking the deposits in all the accounts opened by me/us* together,
as specified in rule 4 and amended from time to time. In case, at any time, any excess deposit is found, such
excess deposit will be refunded to me/us* after recovery of excess interest under sub-rule [(7)] of rule 7.
3. I nominate the following person/persons, mentioned below, to whom, to the exclusion of all other persons, in the
event of my death the amount standing to my credit in the account would be payable in accordance with the provisions
contained in rule 6 :

[TABLE
Sl. Name(s) of the nominee(s) along- Permanent Date(s) of birth of nominee(s) in Share of the nominee(s) in
No. with relationship with the depositor Address case of a minor/age in other case(s) the amount payable
(1) (2) (3) (4) (5)

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 Photograph(s) of the nominee(s) Signature/thumb impression of the nominee(s)
(6) (7)

]
3. (a) As the nominee(s) at Serial No.(s) ...................... above is/are minor(s), I appoint Shri/Smt./Kumari
............................. [name(s) with permanent address(es) of the person(s) in respect of each minor nominee] to receive
the sum due under the said account in the event of my death during the minority of the nominee(s).

............................................................................
Signature/Thumb impression of the depositor
Witnesses (Signature, name and address) :
1 .........................................
2 ......................................... Date .......................... At (Place) ..................
My/our* specimen signatures (thumb impression), are as below :—
(i) First depositor :—

1. 2. 3.
(ii) *Joint depositor :—

1. 2. 3.

#Witness .................................. #Witness .................................. #Witness ..................................

(Countersigned Postmaster/Incharge) (Countersigned Postmaster/Incharge) (Countersigned Postmaster/Incharge)

Date ....................................... & office Seal Date ....................................... & office Seal Date ....................................... & office Seal

4. I also declare that the information provided by me/us* in the application hereinabove, is true to the best of my/our
knowledge and belief and in case, at any time, any of the information and/or declaration is found false, no interest on
the deposits shall be payable to me/us*, the deposit office shall close the account(s) and refund the deposits after
recovery of the interest, if any, already paid on the deposits.
................................................
Yours faithfully,
................................................
(Signature of the applicant)
Date ......................... ................................................
Place ....................... (Present Postal Address)

Enclosures :
1. Age proof.
2. Copy of receipted application form for allotment of PAN, if PAN is not allotted.
3. Pay-in-Slip (Form-D), duly filled in along with amount of deposit.
4. Certificate from the employer as specified in sub-clause (ii) of clause (d) of rule 2.

* : Score out whichever is not applicable.

** : (1) The applicant(s) who are not assessed to income tax, may furnish a self-declaration, that their income from
all sources (including the interest income from the account to be opened vide this application) does not cross
the exemption limit and the applicant is not required to obtain PAN under Income-tax Act, 1961, as amended
from time to time.
(2) All other applicants shall mention the PAN No. compulsorily and in case they have not so far been allotted
PAN by the Income-tax Authorities, attested photocopy of the receipted application form for allotment of PAN

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 should be attached to the application form.
# : in case of thumb impression.
Note : (1) Self-attested copies of any of the following documents can be enclosed as age proof :- Birth Certificate
issued by the Municipal authority/Gram Panchayat/District Office of the Registrar of Births and Deaths; Voter Identity
Card issued by the Election Commission of India; PAN Card; Passport; Ration Card; Date of birth certificate from the
school last attended by the applicant or any other recognised educational institution or Driving Licence issued by the
local licensing authority.
(2) Originals of the documents attached, should also be produced simultaneously for verification and return
immediately.

FOR THE USE OF DEPOSIT OFFICE

The account has been opened on ……………...............……………........ with Rs. …………...................... (Rupees
..................................................................) under the Senior Citizens Savings Scheme, 2004.
Account No. ................................ Ledger folio No. .....................................................................................
Agent’s name, agency code number, date and validity have been entered in the ledger folio as well as Pass book (in
case of account introduced through agent).

Pass Book No. ...................................... has been issued.

Date ................................ Signature of the Incharge of Deposit Office

(along with name and designation stamp)

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