Annexure-II Application for Deceased claim (To be used for cases other than Nomination/Joint Account with survivor

clause) From Mrs. Sumitra Devi H.No.-222 Village Rajpura Post Kharkhoda Distt Meerut U.P To The Branch Manager, Allahabad Bank Hapur Ghazibad Branch Dear Sir Re: Deceased Account Late Shri/Smt Babu Ram Account No(s) 50017829743 I/We advise the demise of Shri/Smt. Sumitra Devi on. He/She holds the above account(s) at your branch. The account(s) is/are in the name of: Smt. Sumitra Devi I/We lodge my/our claim for the balances with accrued interest lying to the credit of the above named deceased who died intestate. I/We am/are the legal heirs of the above named deceased and lodge my/our claim for payment as per the banks rules and discretion. The relevant information about the deceased and the legal heirs are as under. 1. Names in full of the parents of the Deceased: Father: NA Mother: NA Religion of the Deceased: Hindu Details of living (i) Husband (ii) Wife (iii) Children (iv) Father (v) Mother (vi)Brothers (vii) Sisters (viii) Grand Children. If Hindu Joint Family, the name and address of the Karta and Co-parceners with their respective ages. Full Name/Address (i) (ii) (iii) (iv) (v) Mr. Pankesh Mr. Dheeraj Mrs. Kaushal Mrs. Pinki Mrs. Sumitra Devi Occupation Service Farmer House Wife House Wife House Wife Relationship with Deceased Son Son Daughter Daughter Wife Age 42 35 45 32 72

2. 3.

4.

Name or Names of the Guardians of the Minor Children of the Depositor (a) (b) Whether Natural Guardian Whether Guardian appointed by a court of Law in India. If so, attach a certified copy or duly attested copy of such Order In whose custody the Minor/Minors is/are?

NA

: :

NA NA

(c)

NA

Claimant/s Name/s and address in Full (i) (ii) (iii) Mrs. Sumitra Devi H.No 222 Village Rajpura Post Kharkhoda Distt Meerut NA NA

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.

Yours faithfully Place Date : : Signature of Claimant(s) (i) Name of Claimant(s) Mrs. Sumitra Devi Address H.No-222 Village Rajpura Po Kharkhoda Distt Meerut Signature

Enc1. : Performa of Existence Certificate

Manager(Pags)

EXISTENCE CERTIFICATE Ann.no. : LX0017063 TO BE COMPLETED ON OR AFTER 01 JANUARY

This to certify that Sh/Smt Mr Babu Ram whose specimen signature is given below is alive today, the 07 day of Feb, 2011
th

Mr. Babu ram Death on 07th Dec 2009 Death Certificate are enclosed herewith Nominee of Mr. Babu ram is Mrs. Sumitra Devi Annuitant (Sign.) : Certified by Signature: Name: Address/Seal: The Certificate is to be completed by LICI Class 1 Officer/Gasetted Officer/reg Medical Practitioner with Registration No or Bank manager with Seal.