PPBL INTERNAL

Claim 1K A

Claim Application from Legal Heirs

To
The Branch Manager
Paytm Payments Bank Limited
Shop No 1, Ground Floor, Tower D, Skymark One
Plot No, H – 10B, Sector 98,
Noida, UP – 201301 Date :

SUB: Settlement of claims in respect of deceased account holder (without nominee)

Dear Sir/Madam,

I/We would like to inform that Shri/Smt maintaining

account number with your bank died intestate on
at <City. I/We, the undersigned, hereby declare that I/We
am/are the rightful legal heir(s) of the deceased ,
entitled to receive the amount due on the deposit(s). Payment released to me/us in accordance with the
request shall constitute a full discharge of Paytm Payments Bank Limited from its liability and obligations in
respect of the deposit:

Particulars of the account are as follows:

1 Name of the deceased account
holder
2 Account number
3 Date of birth (DD.MM.YYYY) & Age

Particulars of the account where funds to be transferred. (Claimant Details)

1 Name of account holder
2 Account number and IFSC Code

I/We request the Branch Manager, Paytm Payments Bank Limited, Noida branch, to pay the
proceeds of the deposits mentioned above to me as legal heir of
(deceased constituent).

I/ We authorize Paytm Payments Bank Limited to return the pipeline flows to the remitter with the
remark "Account holder deceased" and to intimate me/us. Where after I/we could then approach
the remitter to effect payment through a negotiable instrument or through ECS transfer or through
any other suitable mode in the name of the appropriate beneficiary.

The following documents (photocopy & Original) are provided for due verification. Please return
original documents to us in due course.
 Death certificate (Registered Number)
 Legal heir Id proof & (ID proof Number)
 Legal heir Address proof (Document name)
 Letter of Indemnity

PPBL
PPBL INTERNAL

 Letter of disclaimer
 Bank statement of claimant or Cancelled Cheque
(Bank name and Statement Month)

I/We hereby declare that the above information furnished is complete, true and correct to be the best
of my knowledge and that I/we have not omitted or suppressed any information called for.

Name and Address of Legal Heir

Signature Date:
Place:

-
For Official Use of the Bank

Recommendation:

After proper scrutiny of the claim application, personal interview with the claimant(s) (Nominee(s))
and verification of the death certificate and declaration, I recommended the settlement of deceased
claim as mentioned above.

Signature
Place Name:

Designation:
Date (Recommending Authority)

Approved as recommended:

Signature
Place Name:

Designation:
Date (Sanctioning Authority with Branch stamp)

PPBL
PPBL INTERNAL

Claim 1K B

Letter of Disclaimer
(To be signed by all legal heirs except the person authorized to receive this claim)

The Branch Manager

Paytm Payments Bank Limited
Shop No 1, Ground Floor, Tower D, Skymark One
Plot No, H – 10B, Sector 98,
Noida, UP – 201301 Date:-

Dear Sir,
Re: Settlement of claims in respect of deceased account holder (without nominee)

Account Type Balance

Savings A/c number :
Wallet :

Note :- In case of Accidental Death, Rupay Card insurance guidelines will be applicable

I/We hereby authorize Shri/Smt. (Relation with the

deceased) to receive the claim money detailed above on our and their own behalf. I/We
am/are the legal representative entitled to receive the amount of deposit in the name of the
deceased and that I/We have no objection, if the Bank in pursuance of the request by me/us,
remits/delivers the amount to him/her/them. Such delivery of the payment of the balance in the
above account would be completely binding on me/us and I/we will not question the Bank’s action
in so doing in any proceedings or otherwise. I/We also undertake to bind myself/ourselves, our heirs
and legal representatives not to revoke the declaration made herein. I/We also tender an
acknowledgment signed by me/all of us as a valid discharge of the bank’s obligations in relation to
the monies held by it in the name of (Deceased name).

Sr. Relationship with Deceased Signature

No Name account Holder Age

Date:

Place :

PPBL
PPBL INTERNAL

Claim 1K C

Letter of Indemnity

To,

The Branch Manager

Paytm Payments Bank Limited
Shop No 1, Ground Floor, Tower D, Skymark One
Plot No, H – 10B, Sector 98,
Noida, UP – 201301 Date:-

IN CONSIDERATION OF your paying or agreeing to pay us, the balances in the name of
, the deceased as mentioned hereunder without production of Letters of
Administration or a Succession Certificate to his/her estate or a certificate from the Controller of
Estate Duty to the effect that estate duty has been paid or will be paid or none is due, we hereby
irrevocably agree to indemnify Paytm Payments Bank Limited from and against all claims,
actions, demands, liabilities, costs, damages, losses and consequences of whatever nature that
you may suffer, incur or sustain on account of you having so acted in accordance with the
deceased claim request raised by us.

Account No. Nature of Deposit Balance

Savings Account
Wallet
RuPay insurance against card(In case of
accidental death)

(Names of claimants to whom payment to be made)

being the claimant(s) of the deceased,

Signed and Delivered

1.

PPBL
PPBL INTERNAL

Claim 1K D

Receipt

Received a sum of Rs (Rupees

only, from Paytm Payments Bank Ltd being the proceeds of account

number in the name of _

(deceased) in full and final settlement of my/our claim there against the amount is received

in as under,

PPBL account Number - In my/our name

OR

Account Number with

Bank Branch.

I/We understand that PPBL shall be making this payment to me/us as a Legal Heir of the
deceased Late . I /We do not have any other claim
from the Bank upon receipt of the monies towards the settlement of the deceased claim and
that the Bank stands discharged from all obligations and liability in respect thereof.

Reven
ue
Stamp

Signature Place:

Name and address of Legal Heir Date:

PPBL