Da Forms: Da-1 To Annexure-15 Page 15

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: 2 :
Full Name/Address
Occupation
Relationship with
Age
Deceased
(i)
_______________ ___________ _______________
________
(ii)
_______________ ___________
_______________
________
(iii)
_______________ ___________ _____________
________
(iv)
____________ ____ __________
_____________
________
(v)
________________ __________ _______________
________
(vi) _______________ _________
_______________
________
4. Name or Names of the
: _________________________________
Guardian/s of the minor
Children of the Depositor
(a) Whether Natural
:__________________________________
Guardian
(b) Whether Guardian
:___________________________________
appointed by a Court
of Law in India. If so,
attach a certified copy
or duly attested copy of
such Order
(c) In whose custody the
:___________________________________
Minor/Minors is / are?
5. Claimant/s name/s
:
and address in full
(i)
________________________________________________
(ii)
________________________________________________
(iii)
________________________________________________
I/We submit the following documents.
Please return the original death
certificate to us after verification:
1. Death Certificate (Original + 1 photocopy)
issued by:
______________
2. Letter of Indemnity
We request you to pay the balance amount lying to the credit of the above
named deceased to …………………………………….on my/our behalf.
I/We hereby solemnly affirm that the above statements are true and correct to
the best of my/our knowledge and belief.
Place:
Yours faithfully,
Date :
Signature of Claimant(s)
(i) Name of Claimant
Address
Signature
15

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