DIRECTORATE OF SMALL SAVINGS, PUNJAB, CHANDIGARH

Claim Form for Prize Items of 25th Lucky Coupon Scheme (1-10-2003 to 31-3-2004)

1. Name of Prize Winner(s) __________________________________________________

(in Block Letter)

2. S/o, D/o, W/o ___________________________________________________________

3. Present Address ________________________________________________________
_________________________________________________________
_________________________________________________________

_________________________________________________________
4. Permanent Address _____________________________________________________
______________________________________________________
______________________________________________________
5. Occupation ______________________________ Tel: __________________________
6. Name & No. of Security Purchased _________________________________________
7. Name of the Post Office/Bank of deposit _____________________________________
8. Prize Winning Lucky Coupon No. ___________________________________________
9. Item of Prize ___________________________________________________________

I, hereby surrender that above Lucky Coupon duly signed by me on the reverse, I also
enclose the photocopy of KVP/NSC/Pass Book.

ADVANCE RECEIPT

Received (Name of the Item)_________________________________________________

Date___________________

Sig
nature of applicant

ACTUAL RECEIPT

Received above item_______________________________________________________

Date___________________
Signature of applicant

WITNESS OF THE AGENT

VERIFIED

Dy. Director, Small Savings/Senior District Officer / District Savings Officer