PRIZE MONEY CLAIM APPLICATION FORM - (PB-23)

Date 2 3 0 2 2 0 2 3
The Chief Manager,
CHECK LIST (please mark )
State Bank of Pakistan,
SBP Banking Services Corporation Original and Copy of Prize Bond ✓
__________________________
Photocopy of valid CNIC/SNIC (original seen) ✓
Two Signatures on reverse of Original & Copy of Prize Bond ✓
Dear Sir,
I enclose herewith the DN158777 Number of National Prize Bond(s) of Rs. 1,500/- denomination particularized below and
request to kindly arrange payment of the prize money as the enclosed Bond(s) has/have been declared winning in draw
mentioned there against.

CLAIMANT INFORMATION
Name Sheraz Hassan Shah
(as per CNIC)

CNIC/SNIC No. 3 5 2 0 2 - 2 6 4 7 4 3 2 - 3 CNIC/SNIC Expiry Date December 30, 2026

House No.497, Block R1, M.A Johar Town Lahore
Address
Contact No. +92-345-4072819
Taxpayer Status ✓ Filer Non-Filer Email ID sherazhasann@gmail.com
PRIZE BOND DETAILS
Prize Bond Details Date of Draw Place of Amount of Prize T-24 System ID
S. No.
Series Serial No. Issue No. Issue Money (PKR) (for office use only)
1
2
3
4
5
6
7
8
9
10
Total Prize Money (PKR)
MODE OF PAYMENT OF Up to PKR 18,500/- Cash only Bank Credit
PRIZE MONEY PKR 93,000/- & above Bank Credit
BANK ACCOUNT DETAILS
Bank Name Branch Name
Account Title
IBAN P K
UNDERTAKING
I hereby declare and accept that:
1. The National Prize Bond(s) presented by me for prize money claim is/are “Genuine”. In case the bond(s) is/are found forged/tampered, SBP BSC (Bank)
reserves the right to take legal action against me as per the relevant laws.
2. The information provided above shall deemed to be true & complete and any misinformation/incorrect details or concealment of facts of any nature
whatsoever by me can result in legal action against me as per the relevant laws. In case of change in any of the aforementioned information including
taxpayer status i.e. Filer / Non-filer, it shall be my responsibility to inform in writing the respective SBP BSC office immediately.
3. The aforementioned bank account is maintained in my name at the bank as stipulated above.
4. Any discrepancy found in the above bond(s) at later stage, the amount of prize money so released would be refunded by me.
5. The Withholding Tax on prize money amount will be deducted at prevailing rates.

________________________________________ __________________________________________________
Signature / Thumb Impression of the Claimant Officer/S.O. (Original CNIC/SNIC Seen by SBP BSC Official)
DO NOT WRITE BELOW THIS LINE / FOR OFFICE USE ONLY
No. :- KHI/LHR-_________________________________________________ PAID CASH STAMP (Upto Rs. 18,500/-)
Date of receipt of claim ___________________________________________
System generated acknowledgment receipt issued to claimant:
YES (No.___________________) NO (Reason)_________________
(PB-23) (To be filled by the SBP BSC Office). The particulars of Prize Winning Bond detailed below of Rs. __________________ denomination attached with the claim application have been verified from our
record and found in order in all respect / not found in order. The condition of the Bond is accepted / is not accepted.
Prize Bond Details Draw Amount of Withholding Tax Net Amount Bank Credit Details
S. No. T-24 System ID
Series Serial No. No. Prize Money Rate Amount (PKR) Payable (PKR) FT Number Date
1
2
3
4
5
6
7
8
9
10
Total
Prize money claim of aforementioned prize winning National Prize Bond(s) is admitted / rejected.

Officer Senior Officer ACM (PBU) IMU Official DCM/CM Officer / Sr. ACM (PBU) IMU Official
Officer
CLAIMANT’S ACKNOWLEDGEMENT FOR OFFICE USE ONLY
Received [please tick ( ) the relevant]: Payment made vide:
I authorize SBP BSC office to credit the prize money amount as well as face value (if applicable) to my bank account as provided on obverse side. Bank Credit
Cash Rs. ________________________ (Rupees______________________________________________________________________) for prize
Cash
money and face value/bonds (if applicable) against ________________ prize winning bonds.

Claimant’s Signature -1 Claimant’s Signature -2 Signature Verified