Buds act 2019 के तहत जमा राशि को वापस पाने के शिए भुगतान दावा

सेवा में,
श्रीमान सक्षम अधिकारी (Buds act 2019) .......................................................................................................................................................................................................................................................... ...................................................................................................................

कार्ाािर् का पता -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- ----

जजिा एवं राज्र् का नाम --- ---------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- ---- --------------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- ----

ववषर्:- Buds act 2019 के तहत अपनी डूबी हुई रकम को वापस पाने हेतु राज्र् द्वारा ननर्ुक्त सक्षम
अधिकारी के समक्ष भुगतान हेतु आवेदन ।

महोदर्,
विनम्र ननिेदन है कि मैं प्रार्थी / प्राधर्थानी का नाम ---------------------------------------------------------------------------------------------------------------------

वपता / पनत का नाम -------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- ------------

आर्ु --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --

मोबाइि नंबर -------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- ---------------

पता ----------------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --- --------------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- -------------- --------------- --------------- --

Saving Account No. ------ --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- -
IFSCode --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --

बैंक िाखा का नाम एवं पता -- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- - --- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -

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

ने िंपनी िा नाम एिं ब्ांच िा पता -- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- - --- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -

--- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- - में ददनांि - --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- िो अपनी मेहनत िी रिम
--- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- (राशि िब्दों में ) -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- जमा किया था जो उपरोक्त ठग
िंपनी /सोसायटी /फमम /िारपोरे िन /समह
ू ने मेरी जमा राशि िो धोखाधड़ी से ठग शिया है और अनेिों बार भग
ु तान िरने िी मांग
िरने िे पश्चात भी मेरी जमा राशि ि अन्य िाभांिों िा भुगतान नहीं किया है।
िंपनी /सोसायटी /फमम /िारपोरे िन /समूह ि उसिे प्रबन्धिों िा यह िृत्य गैर िानूनी एिं Buds act 2019 (अननयशमत जमा योजनाएं
पाबंदी िानून 2019) ि PID Act िा उल्िघंन है जो आई पी सी 1860 िी धारा 420, 406, 409, 120बी िे तहत एि संगीन जुमम
एिं दंडनीय अपराध है।
मैं प्राथी / प्रार्थमनी उपरोक्त िंपनी /सोसायटी /फमम /िारपोरे िन /समूह िा ननिेिि अथिा ननिेिि िा नाशमनी हूूँ और
ू ी रूप से जमा राशि िा तीन गन
Buds Act 2019 िे तहत िानन ु ा रूपए ----- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- - (राशि िब्दों में) - --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -

रूपये (हजामना सदहत) भुगतान पाने िा अर्धिारी हूूँ।

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

अतः श्रीमान जी से विनम्र अनरु ोध है कि उपरोक्त ठगों से मेरी जमा राशि एिं अन्य िाभांिों िो िसि
ू िर तय समय सीमा
180 ददन में मेरा भुगतान िराएं और ठगों िो दंडडत िरिाएं।
घोषणा / िपथ
मैं सत्य ननष्ठा पूिमि घोषणा िरता / िरती हूूँ कि उपरोक्त वििरण मेरे ज्ञान िे अनुसार सत्य एिं ठीि है और इसमें िोई
तथ्य छुपाया नही गया है।
मैं आिेदि अपने दािे में आिश्यि संिोधन िरने िा अर्धिारी हूूँ l

ददनांि - --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- --- -- --- --- -- --- -- --- --- -- --- --- -- --- हस्ताक्षर
प्रार्थी / प्राधर्थानी

संिग्न
1. आधार िाडम या िोटर िाडम िी छायाप्रनत 2. ननिेि प्रमाण पत्र िी छायाप्रनत 3. पासबुि िी छायाप्रनत
2.
वििेषत :- अपनी जमा राशि िा तीन गुणा धन प्िस ब्याज एिं अपने हजामने िे साथ भुगतान राशि शिखें। अनतररक्त सूचना एिं अनेिों बार ननिेि किया है तो उसिा
ब्यौरा दे ने िे शिए इस आिेदन िे पीछे सादा िागज िगा िें l