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NOMINATION FORM FORM DA1 Date DDMMYYYY CUSTOMER DECLARATION Nomination under Section 45ZA of the Banking Regulation Act 1949 and Rule 2 1 of the Banking Companies Nomination Rules 1985 in respect of the bank deposits. I/We Name s Address es nominate the following person to whom in the event of my / our / minor s death the amount of the deposit particulars whereof are given below may be returned by Citibank N.A. Branch Name and Address DEPOSIT DET.

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