Claim Application Form ‘an argu Rrie/Claim Request Date:14=10:2023 fra mtzanetza,/ Dear Sir/Madam, 3, qq ara, Full Nat daday Ranjitsinh Abhesinn Revaft 1 ara/Father/Husband NameS/Q; Abhesinh ‘we al rth: 06-11-1979, yu gu Me Previa Bes Baw wo ach et safety tereraer) 2 rem za FQ oT A: Date of Birth:06-11-1979, do hereby apply for a claim against my ‘deposit(s)/ contribution(s) amount which is to be credited to my following Bank :~ Sign across he photo ‘ewrate/Bank Name: STATE BANK OF INDIA 24 sa of aa Per ROE: Following are my deposit det = sires | am fperrrerrrsslare theaters} = sao | atereat | stor rele aeqwa | of | ert weer) ar feta |e jem] ster | a mts | toms wae | ey | aes Membership | wo. feces -orieate/}Recount! Deposit | ne, No. | Code | Name a eT pate, | amount e Pal] Amt RRepal Repaid} «| © e 31-05- 1 fsccst} 0 |14301400864)14305101031} 70077 | ona | 7000 o jo} o at / Declaration ‘aoa gra fret sat ‘ Jadav Ranjitsinh Abhesinh wasra don sca & PF # Sahara Credit Cooperative Society Limited. fia f. ar Uw sree: semremaleeer Ae AA we orgs oa sae ey ser & orga va AAG A a on rer 1 BA aoe ‘aR aA en ahora HE aren ren aE aot enreeh a Peace ert seca veer ween RA ra She Ravana ra SheSke rn fen afte aotitfe shereAl A, steer I os 8 Pere 22.03.2022 2 aa Be werd edicts SRE ahr £2,, 2eaare Al zm A Pears 29.03.2023 % wea Dt tales sansa arg % orzeers A fem na? 1 1. Jaday Ranjilsinn Abhesinn_ hereby declare that | am a genuine depositorfmember 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 Lid., Hyderabad and in compliance with relevant Income Tax Laws. 2.72 gm aries ates oa 8 A ot at A aa ae as we a afta et, 8 Laer OP as oe wt Oe “aera-dfisrcdiea thes ora’ 1 ave act ate ‘aeratisrcdiqa thos erat 8 aaa as a aft 8 1 aren exer 1 ‘arora acueatiegs Chee waren" res Peer mg crenata ten ae Be wea A Peal ona ate Bae wererarserseh 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. I shall also not pursue the claim in other forum to the extent it is settled by the ‘Sahara-CRCS Refund Account’. 3. Fae ota, Ball aera a Reea-vagAl a9 ean 8 as & orga Beall fRRet at orate Fae Fy 8 seer of ceT I. 3. Further, | shall also be liable for any civil or criminal action in accordance with law, in case of any falsehood or misrepresentation. anred wa BEETS ‘afta/Date: 14-10-2023, RAINY... RD. ignature of Depositor: MK ‘sureai 31 374/Name of DepositorJadav Ranjitsinh Abhesinh Har/Place: atarra ta! Mobile No: €-9 3.9 OUGS LE, - CO-43ZU BSR