Design & Developed By: Komal Pingle

DEPUTY MANAGER– Cell: 9407279977

Version: 1.0 Dated: 27.07.2018
NAME BRANCH WITH CODE PANNA CITY (12174)
BM DESIGNATION BRANCH MANAGER

NAME OF NOMINEE SHRI LALIT MODI

REALATIONSHIP WITH DECEASED SON
NOMINEE HAVING SBI A/C YES 30654377980
ACCOUNT MAINTAINED BRAMCH SBI BENISAGAR PANNA(31285)

ADDRESS OF DECEASED LINE1 GANDHI NAGAR

LINE2 BALAJI MANDIR
LINE3 BHAT MOHALLA
CITY ITARSI
PIN 488001
MOBILE 9407279977

NAME OF DECEASED PERSON LATE SHRI VIJAY MALYA

DATE OF DEATH 01.01.2018 AMOUNT
SAVING A/C 10930404151 1,111.11
STDR1 2.00
STDR2 3.00

DEATH CERTIFICATE NO : REG211588895

DEATH CERTIFICATE DATE: 01.01.2018

ADDRESS OF NOMINEE LINE1 LINE1

LINE2 LINE2
LINE3 LINE3
CITY CITY
PIN 488001
MOBILE F

NAME OF WITNESS1 KOMAL PINGLE

ADDRESS WITNESS 1 GANDHI NGAR BALAJI MANDIR ITARSI
NAME OF WITNESS2 KOMAL PINGLE
ADDRESS WITNESS 2 GANDHI NGAR BALAJI MANDIR ITARSI
SANCTIONING OFFICER MANAGER OPERATION
CONTROLLING OFFICER BRANCH MANAGER
CONTROLLING OFFICE ADDRESS SBI CITY BRACH (12174)
SHRI LALIT MODI
GANDHI NAGAR
BALAJI MANDIR
BHAT MOHALLA
ITARSI

To
The BRANCH MANAGER
State Bank of India
PANNA CITY (12174)

Sub: Request for claim settlement of a deceased account: 10930404151

Dear Sir/Madam,

With profound grief, I want to intimate that both my parents, who were account holders of a
savings account in your bank, now cease to exist. For your reference and necessary action, I
am attaching the death certificate of LATE SHRI VIJAY MALYA along with this application form
and other necessary documents.

LATE SHRI VIJAY MALYA in their lifetime had nominated me as the sole nominee of the
saving account. I thus request you to please close the account and settle the proceeds in my
name. In this respect I have filled up the nominee claim form in its entirety. I have also taken
the signatures of two persons as witnesses who are known to me. The ID and address proof of
both the witnesses are attached along with this application.

I have further attached Copies of my ID and address proof are also attached along with this
application for your kind consideration and necessary action.

Names of account holder:

LATE SHRI VIJAY MALYA
Savings bank account number: 10930404151

Thanking you
Yours truly

(Signature)
SHRI LALIT MODI
DATE:
PLACE: PANNA CITY (12174)
Encl:
1. Pass book/ATM/Cheque Book
2. Nominee claim form
4. Copy of ID and address proof of nominee
5. Copies and address proofs of both witnesses
6. KYC self
7. KYC of Deceased Person
 ENTER ADDRESS ONCE
HERE

Tel : BM: E-mail :sbi.XXXXX@sbi.co.in

Fax : Mobile- Date: 8. Jun. 2019

SHRI LALIT MODI

GANDHI NAGAR
BALAJI MANDIR
BHAT MOHALLA
ITARSI-488001
MOBILE : 9407279977

Dear Sir/Mam,

CONDOLENCE LETTER

We have been inform by SHRI LALIT MODI, SON of LATE SHRI VIJAY MALYA that
he/she passed away on 01.01.2018 Death Certificate No. REG211588895 issued on
01.01.2018.

Please accept our deep condolences on the death of LATE SHRI VIJAY MALYA. It is
very tough for us to believe that now LATE SHRI VIJAY MALYA is not with us.

But as we know that it is the circle of life, and we have to accept hard realities of death.
I know that as a family you have a hard time ahead; our condolence with the family of
LATE SHRI VIJAY MALYA. May God help you and give family a strength to overcome
from this tough time. We are working to get the post-death claims settled as soon as
possible, and in the meantime you are free to ask for any help. Feel free to contact our
branch in need.

With deep sorrow

Yours Faithfully

Branch Manager
 SBI PANNA CITY BRANCH
BADA BAZAR
PANNA – 488001

Tel : BM: E-mail :sbi.XXXXX@sbi.co.in

Fax : Mobile- Date: 8. Jun. 2019

SHRI LALIT MODI

GANDHI NAGAR
BALAJI MANDIR
BHAT MOHALLA
ITARSI-488001
MOBILE : 9407279977

fiz; egksn;@egksn;k

laosnuk i= & LoxhZLATE SHRI VIJAY MALYA

gesa
SHRI LALIT MODI ds }kjk Kkr gqvk gS fd
Jh@Jherh dk LoxZokl dks gks x;k
LATE SHRI VIJAY MALYA 01.01.2018
fnukad gSA
mDr ifjis{k esa ge viuh laosnuk izdV djrs gSaA RkFkk bZ'oj ls
izkFkZuk djrs gSa fd bl dfBu le; esa ifjokj dks foifRr dk lkeuk djus
dk lkeZF; iznku djsaA
mudk Hkkjrh; LVsV cSad ls fj'rk ,d ifjokj ds rkSj ij jgk gSA ge mudh
e`R;q mijkar muds
}kjk pyk;s tk jgs [kkrksa dk fuiVku 'kh?kz djus ds fy, iz;kljr gSaA

muds [kkrs lacaf/kr tkudkjh rFkk izdj.k fuiVku dk;Zokgh gsrq vki 'kk

vR;ar [ksn ds lkFk--

Hkonh;

'kk[kk izca/kd
THE BRANCH MANAGER
STATE BANK OF INDIA
PANNA CITY (12174)
PHOTO OF
NOMINEE

Dear Sir/Mam

CLAIM AS NOMINEE FOR PAYMENT OF BALANCES IN THE

SB/CA/RD/(S)TDR ACCOUNT OF LATE LATE SHRI VIJAY MALYA

I SHRI LALIT MODI(Nominee) hereby declare that I am the Nominee / Appointed as

Guardian on behalf of a Minor Nominee in the Account(s) of Late (Deceased) who has
expired on 01.01.2018.

I, therefore submit My Claim as a Nominee/ Guardian on behalf of Minor Nominee for the
balance available in Accounts as per details given below with interest to be paid to me.

Sl No NATURE OF A/C NO AMOUNT DATE OF Nature of Liability AMOUNT

DEPOSIT MATURITY to
(SB (If TDR) the Bank
/CA/TDR/RD) (if Any)
1 SAVING A/C 10930404151 1,111.11
2 STDR1 0 2.00
3 STDR2 0 3.00
4 0 0 0.00
5 0 0 0.00
6 0 0 0.00
TOTAL DEPOSIT 1,116.11 TOTAL OF BANK LIABILITY
AMOUNT

I have enclosed all the documents mentioned below for your perusal and settlement of
the claim.

DOCUMENTS ENCLOSED:-
Yours faithfully,
1. Passbook / (S)TDR of Deceased (In original) ( )
2. Cheque Book of Deceased ( )
(Signature of
Nominee/PersonAppointed on behalf
3. ATM Card of Deceased ( )
of minor Nominee) 4. Death Certificate ( )
Date: ____/_____/20___ 5. Nomination receipt CBS PRINT ( )
6. Identification Proof of the Nominee ( )
(Showing relationship with Deceased) ( )
7. Address proof of the nominee ( )
 8. KYC OF WITNESS 1 & WITNESS 2 ( )
8. Any other document _________________ ( )

Address for Correspondence (Nominee):

SHRI LALIT MODI Witness (1) ______________________________

LINE1 NAME: KOMAL PINGLE
LINE2 ADDRESS: GANDHI NGAR BALAJI MANDIR ITARSI
LINE3

CITY Witness (1) ______________________________

488001 NAME: KOMAL PINGLE
F ADDRESS: GANDHI NGAR BALAJI MANDIR ITARSI

------------------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY

Report of the Recommending Authority: -

I have made necessary inquiries about the claim made by the Nominee / Guardian on behalf of
the Minor Nominee & satisfied that the claim may be settled. All the necessary documents
have been obtained. The claim may be paid to the Nominee / Guardian on behalf of the Minor
Nominee.

Any other Remarks:

Place: PANNA CITY (12174)

Date: ____/_____/20___

Name & Designation : ______________________ Signature with Date

(Recommending Authority)

Sanctioned and Payment to Nominee / Guardian on behalf of the Minor Nominee

Allowed:

Place: PANNA CITY (12174)

Date: ____/_____/20___
Name & Designation : ______________________ Signature with Date
(Sanctioning Authority) MANAGER OPERATION
Disbursement & Record:

Amount of ₹ 1116.11/-(Rupees_______________________________________) paid

by way of Banker’s Cheque No.____________ Dated ___/____/20__ and receipt obtained."

OR'

Credited to Nominee’s Account No 30654377980 maintained with SBI BENISAGAR

PANNA(31285) Branch and copy of statement of account carrying the relevant entry
maintained on record as part of the claim settlement.

Place: PANNA CITY (12174)

Date: ____/_____/20___

Name & Designation : ______________________ MANAGER OPERATION

(Sanctioning Authority)

------------------------------------------------------------------------------------------------------------------------------

RECEIPT
(In Case Payment to Nominee/Guardian of Minor Nominee made through BANKER’ CHEQUE)

Received from State Bank of India, PANNA CITY (12174) Branch an Amount of
₹______________/- (Rupees___________________________________________)

by way of Banker’s Cheque No.____________ Dated ____/____/20___ towards full and final
settlement of Balance to the credit of SB/CA/RD/(S)TDR Accounts as above in the name of
Late LATE SHRI VIJAY MALYA.

Date: ____/_____/20___ _____________________________

(Signature)
SHRI LALIT MODI
GANDHI NAGAR
BALAJI MANDIR
Stamp of Rs.
1X10 =10 Rs. BHAT MOHALLA
ITARSI
 CONTROL RETURN FOR DECEASED CASE WITH NOMINATION
PANNA CITY (12174)
To,
BRANCH DOCUMENT
THE BRANCH MANAGER
SERIAL NO
STATE BANK OF INDIA
SBI CITY BRACH (12174)

DISPOSAL OF DECEASED’S ASSETS WITH NOMINATION FACILITY

(1) NAME OF DECEASED : LATE SHRI VIJAY MALYA
(2) DATE OF DEATH : 01.01.2018
WHETHER DEATH CERTIFICATE HAS BEEN
(3)
OBTAINED : YES
WHETHER NOMINATION IS REGISTERED
(4)
WITH OUR BANK RECORS : YES
(5) SEGMENT OF THE ACCOUNT(S) /ASSETS : PER
(6) PARTICULAR OF DEPOSITS / ASSETS:
(I) TYPE OF DEPOSITS (SB/CA/TDR) : SAVING A/C,STDR1,STDR2,,,,,,
(ii) ACCOUNT NO(S) : 10930404151,,,,,,,,
(iii) TOTAL AMOUNT INVOLVED : र.1,116.11
WHETHER THE UNUSED CHQ LEAVES /ATM
(iv)
CARD HAVE BEEN TAKEN BACK : YES
WHETHER DECEASED HAD ANY BANK
(7)
LIABILITIES (GIVE DETAILS) : NO
WHETHER THE ABOVE LIABILITIES HAVE
(8) BEEN SETTLED BEFORE DISPOSAL OF THE : YES
ASSETS OF DECEASED
(9) NAME OF NOMINEE : SHRI LALIT MODI RELATION SON
IN CASE OF ANY MINOR, THEY HAVE BEEN
(10)
REPRESENTED BY :
WHETHER ASSETS FROM PART OF THE
(11)
SELF ACQUIRED ASSETS OF DECEASED. :
WHETHER SATISFIED BY INDEPENDENT
ENQUIRIES AS TO THE CORRECTNESS OF
(12)
THE PARTICULARS FURNISHED BY THE : YES
NOMINEE
NAMES OF THE CLAIMANTS IN WHOSE
(13)
NAME CLAIM WAS SETTLED :
(14) DATE OF SETTLEMENT / DISPOSAL :
[ ] REVISED CLAIM FORMAT
[ ] DEATH CERTIFICATE OF DECEASED
[ ] P/B, ATM CARD, CHEQUES, TDR RECEIPT
[ ] IDENTITY CARD OF NOMINEE
[ ] ADDRESS PROOF OF NOMINEE
(15) DOCUMENTS TAKEN : [ ] NOMINATION PROOF
[ ] KYC OF WITNESS1
[ ] KYC OF WITNESS2
[ ]
[ ]
[ ] OTHER :
REMARKS:
We have paid / settled the above Decease Claim after conducting the concrete enquiry and taking the required
documents as mentioned in Column: 15 under Branch Manager Discretionary Power and as per Delegation of
Financial power vide E-Circular No: CDO/ORG-DFP/5/2014 – 15 dated 03-11-2014.
Submitted for your Control Please;

MANAGER OPERATION DATE : 8. Jun. 2019

CONTROLLED