aa aqda Raia/Claim Request Date:03-10-2023 ‘fia nétca/nttem,/ Dear Sir/Madam, | tl a +, qua, Full Namedadav Nansang Mavabhai | ‘avait #1 atH/Father/Husband NameS/O: Jadav Mavabhai Sac eeaweet/ ‘yr a arth; 01-06-1978, Fae ga Rt evkefea Ae H an a ar sn ocroes he a sonata) fers a fe ae wR - Rca Date of Birth: 01-06-1978, do hereby apply for a claim against my deposit(s)/ contribution(s) amount which is to be credited to my following Bank =~ ‘a a a/Bank Name: STATE BANK OF INDIA 2 om oft a Barn BAA: Following are my deposit details: = safes | asm soso: fare aeareerc aa za | deed afte age | of | gern weer a) a AAR uw liens] ate aia! jie] | meal | ef [am ey i Membership cl pecs ee ent PB etfloan fPiaimpsociety) yo, aa No Pi) Passbook (pening|Contribution| vat eb a . ti i Noe No, | Date | Amount e Patsy) Am Repaid Repaid] ¢ | & z 31-12 4 |scest|14301105698|14303702953) js009s407637/ | 10000 o |olo aaah re Pr rar pai meen hem ara # BB Cahara Credit Crnnarative Gaciaty limited mA wohl ® ledaw Nancana MFarara 8 acca She anf 8 SAC rey sen Ae ad az ae ares Ren 1 sea soTayamTara A gra Sahara Credit Cooperative Society Limited, af @. 4 AR au ara 8 wer Hie atsicthea dened ., ETH; TERT aRata neds da @., due ste wor ean He Asta dad @., Aen at ant Rate 22.03.2022 & weet Ste werd wedinda siatitiea dared (., Revere wf aan 7 Rais 29.03.2023 % qed te ‘eafita rae erqr & sequreta 8 Arn arene 1 1, Jaday Nansang Mavabhai. hereby declare that | am a genuine depositor/member of Sahara Credit Cooperative Society Limited, Society Ltd. and have made legitimate deposits in this Society as per the details given above in this application form. | have given details of all the deposits made by me in the above Societies in all the Schemes. The aforesaid information given above is true and correct to the best of my knowledge and belief and | have provided true proof of my deposit and claim. The said deposit(s) were made by me in the Sahara Credit Cooperative Society Limited. Society Ltd. out of my legitimate income before 22.03.2022 in case of Sahara Credit Cooperative Society Ltd., Lucknow, Saharayn Universal Multipurpose Society Ltd., Bhopal and Humara India Credit Cooperative Society Ltd., Kolkata and before 29.03.2023 in case of Stars Multipurpose Cooperative Society Ltd., Hyderabad and in compliance with relevant Income Tax Laws. 2. af Be gra seekege onees aa Hh rg ang oA erat arg A vera aT een ant aS, A ar ses UP Aiea Shee aT aft ‘aenedioneign tthe aren’ # arma #e ah ‘uerraionetes Aes arn’ 4 saa of at afahl ae af aaron ama € 18 ‘aenedisniea dos ar’ ga feet om aaratt af din ae} aa at fel seer a Het sarsm/serst 1 2. If any of the information given by me in the above application form is subsequently proven to be incorrect or false, | hereby undertake to return the refunded amount along with the applicable interest to ‘Sahara-CRCS Refund Account’ and indemnify the “Sahara CRCS Refund Account’ to the said extent. | shalll also not pursue the claim in other forum to the extent it is settled by the ‘Sahara-CRCS Refund Account’. 3. seh often, Pratt srecrar an Proenwead af car 8 area & organ Pet eter ae sera gaa 2a F sacar ot xem, 3. Further, | shall also be liable for any civil or criminal action in accordance with law, in case of any falsehood or misrepresentation. Aa dic yl atl -aurerci 1 Baia Signature of Depositor: adta/Date: 03-10-2023.