(To be executed by the Claimant in case of claims without nomination and without succession

certificate, on non-judicial stamp paper of Rs. 50 or as prescribed in the circle concerned,

whichever is higher)

AFFIDAVIT

I………………………………………… aged about…………, husband/wife/son/daughter etc

of late……………… (name of deceased policyholder), resident
of…………………………………hereby solemnly affirm and declare the following:

1. That the said late deceased policyholder died intestate and did not leave any will.
2. That I am the only successor to the estate of the said deceased policyholder or all
other legal heir(s)/successor(s) have relinquished his/her/their interests &
rights in the claim proceeds of the said deceased policyholder in my favour.
3. That I have not submitted claim for any PLI or RPLI policy of the said deceased
policyholder with Department of Posts.
4. The details of all PLI & RPLI policies of the said deceased holder is/are as
follows:

Sl. Policy number Type of policy/plan Sum Assured Date of

Acceptance

5. I hereby held myself and my family bound to the Department of Posts

(hereinafter called India Post) for the sum equal to the total claim amount, to be
paid on demand or without demand to India Post, its attorneys, successors or
assigns or representatives for which I bind myself, my executors, administrators,
successors, and representatives, firmly by this declaration.
6. In case any information is found to be wrong, misleading or deceptive in any
manner, at any stage, before or after settlement of claim, my claim may be
rejected or I shall be liable to refund all the money (total claim amount received)
with interest to India Post, as the case may be, and shall also be liable to be
prosecuted under relevant provisions of laws.

I solemnly state that the contents of this affidavit are true to the best of my
knowledge and belief and that it conceals nothing and that no part of it is false.

Dated:
Place:

Deponent
Notary Public