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17

Annex-5

Request Slip for exchange of Old High Denomination Bank Notes


in denominations of ` 500/- and ` 1000/-

Name of the Bank


Branch:_________________________________________________________

Name of the Tenderer

(In capital Letters)

Identity Proof Original Aadhaar Card, Driving License, Voter ID Card, Pass
to be shown at the Port, NREGA Card, PAN Card,
counter
Identity Card Issued by Government Department,
(Tick the one Public Sector Unit to its Staff,
applicable)

Identification Number

(Number mentioned in
the Identity Proof
submitted)

Details of Old High Denomination No of Pieces Value


Denomination Bank
Notes submitted for ` 500
exchange
` 1000

TOTAL

Total value in words:

Signature of Tenderer

Place:

Date:

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