r e SB I Application Form for Settlement of Claim of Deceased Constituents for payment of balances in accounts, articles in safe deposit locker and safe custody in ‘cases other than Nomination or Joint Account with survivor clause) | {Applicable for Resident/Non-Resident) Banks, Branch: To, ‘Address for correspondence ‘The Branch Manager, Shri/ Smt /Kum Address: Contact No. EmailiO | Date: —— Madam / Dear Sir, Claim for Payment of Balances in the account (s) and delivery of articles.in safe deposit locker/safe custody of Late Shri / ‘Smt /Kum. expired on. 17 We advise that Shri / Smt / Kum expired on. is missing/ not traceable since 2. Late Shri / Smt / Kum, was maintaining following Accounts / safe deposit locker /safe custody articles In your Branch: REI itea iguana rAmeunured Shave jifenyEeriaeatah BU Siege] Total Amt. Total Amt. “(the actual amount of claim with accruedinterest willbe worked out on the date of payment.) b.Safe Deposit Locker No. Mode of Holding, ¢. Safe Custody Article Recelpt No. Details of Articles: +3.1/Me lodge my / our claim for the above balances with accrued interest/ articles in safe deposit locker /safe custody of the above-named deceased in terms of: (Select which s applicable) (Duan ortne tate shes Smt / Kum dated and a probate granted by the court of at dated. (Copies enclosed).Succession Certificate cated granted by the Court of — (Copy Enclosed). $ Di tetter of Administration No dated issued by ———__t Copy enctosed. | [the deceased cies intestate, IWe lodge our claim without @ legal represen tation for payment as per the Bank's rules discretion. ~ awe furnish below the required information about the deceased & the legal heirs in this regaré:= fa) Date& Place of Death (b) Details of Death Certificate No. doted ______ Authority (copy enclosed) (Original to be produced fer verification.) | {c) Age. Yrs. | (q) Marital Status- Married / Unmarried/ Widowler) (e) Permanent Address | | | HNosFiatNo, Street Name. Locality/Village | } cayrDistret, State, PIN. | | | (Religion Which law of successionis applicable, (Hindu, Mohamedan ete) {g) Name (2), Relation (s} & age (s] of the legal heirs of the decease ARE Aloe MC ieee Birt eis Cee ely Se iigechoistiatmen rez/t CTL: | | | | {h) Name (s) of the Minor (s) & Natural Guardian (s) / Legal Guardian (s) of ‘minors amongst the claimants. | Feofpianeliemeetiie jnelstlanship|umaaluunetnerssecurinapenteron| eiicue dion} ih Micorsiiiiim uDisclalmaclyes/Na)s ——— | =| years and isunconnected with our family, | Vknow the ddceased and his/her family since last __ | Shri / Smt / Kum. ive. the person furnishing the declaration below / the | affidavit [Annexure “B") knows our family fortast | years. The person(s) named above is/are the only egatheir(s) of tne deceasedenttled to succeed to the estate ofthe deceased. lamnotrelatedinany manner whatsoever tothe deceased | cor any of the above-mentioned persons mentioned at ig) to (h] above, nor have | any claim nature in the estate of the deceased. or interest of whatsoever Certified thatto the best of my knowledge &| belief the facts stated above are trus &.cortect mene er na pene cig te Sucre gre Place Signature Date 6, Wepropose the folowing surety(ies: No surety required for amounts uP 19 threshold mith L_] | \ \ Jo ire declare that the facts stated above are true and correct tothe ‘best of my/our knowledge and beliefs -the amount of claim settled including up to date applicable interest may kinaly be issued Banker's cheque/ credited to the account standing in the name of ior, —____ maintained with _ ee ne ATGSINEFT. = Tigntre ote cimart s)he wirecevete amount aes of fe eres eke SAE SASSY EE Sess Place:_____— Date :___ Encl As above. [ot he Bonk ts not responsible for any delay n disposal of the Cin oot To Tack of full particulars furnished in this Spntcation and may insist on caling fer a Legal By presentation incase there are disputes emonglegal hes 521 ofthem do, | Set jon in indemmifying the Bank (Or sive letter of rraataet) of where the Bank has reasenable doubt about the Genuneness of the laimant(s} being the only eis) ofthe ‘deceased customer. firtnc space providedis insufficient please use adaitional sheet)Ihave made fecessary inquiri ry inquiries about the cli Uhovemade ecessnry in claim made by the oants&satisied that the —— ee up-to %5,00,000/-)* / Surety/ les offered are acceptable feet el scant nett A the tinbnteiyensonare “(Strike outifnot applicable) Any otherremarks: | Place: Signature ow Name ate, Designation = (Recommending Authority) ‘Sanction: Sanctioned paymentof®, @, ) inaccounts/ handing over of contents/artciesin Safe Deposit Locker/Safe Custody of Late to claimant(s). Signature Place: Date____— {sanctioning Authority) Disbursement & Record: ‘Amount of" et byway of []eanker'scneauent. pated ___endveceiptobtoined. creed to camntsAedunt o_o ranch il ogy of Creed can he rlvaenrmartansonecoréspaeribecinsetre maintained in India with Bank, Ceredted to cimant’s Account Ho branch tough RTGS / NEFT vide UTR NO Dated = = adegunerf devo vaner cet minaaden srr ssp0cf NSA settement vans ovr omerisfariesct fe cepesbokeate ce vccountiveexpt to daimant and acknowledgement opt onrecordas part of the claim settlement: pertain to this laim settlement have been KePt On Branch record. Allthe documents, signature Place:___—— Name t Designation : Date, {Disbursing Authority)@ STATE BANK OF INDIA DEBIT SLIP ' coimBaTore (00827) —E DEBIT Rupees aeRO od ee ro BEING DECEASED SETTLEMENT BC GIVEN TO NOMINEE/LEGAL HEW2 NOMINEE/LEGAL HEIR OF THE DECEASED PASSING OFFICER "AUTHORISED OFFICIAL ATORE (0082 COIMBATORE (00827) yd. Branch BANKERS CHEQUE APPLICATION | IN FAVOUR OF (IN BLOCK LETTERS) @© |Banxers CHEQUE Rupees. ] DETAILS | AMOUNT (Rs.) _ BC AMOUNT PAYABLE AT (BRANCH) BRANCH CODE | EXCHANGE | COIMBATORE 827 ToTAL__| pan. naive Ano AGDRESS OF THE APPLICANT stobile No swO [PASSING JOURNALNO DD/BC No. [siGNED RECEIVED THE DRAFT APPLICANTRECEIPT RECEIVED from the Branch Manager, STATE BANK OF INDIA, asum of... .. Rupees.. va. only) being the balance in the Account No. .... in the name of a. SINCE deceased in full and final settlement of the claim. Date : |_| Witness: Claimants.| nnexure- \ . LETTER OF DISCLAIMER, fonearech (Tobe stampedas per the Stamp Ack applicable to the State) The Branch Maddager Dear Sir, 7 | N *AccountNo, inthe name of Shri/Smt./Kum.. Balance’. With reference to the above account, I/We, the following egal heirs ofthe late Shri/Semt./Kumn, (name of the deceased account holder), have to advise that we have no interest in the above assets and as such we have no ‘objection to your paying the balance amount yingin the above account(s) with youn the name ofthe aforesaid Shei/Smtskum, | tte me of the deceased account holder to Shri/Smt./Kum. 1 ve sceons) would be completely binding onus andwe wnat question saundelveryoftnepaymentofthebalanceinthe above accounts woulabe complete suey aeivn ain rayne ning io unsoaoncrees ou ae andigalrepssenatie nat ade eran Signed before me this__=dayof omen celeet Notary Public/Magistrate) urrent ete sin here the type of account viz, $B/8.0/Term Deposit, CurrentAnnexure c. LETTER OF INDEMNITY (To be duly stampedas per the Stamp Act applicable to the State) Indemnity with respect to payment of Balance in the: Account without production of Legal represer 5 (Letter of Deceased Constituents ;ntation) To, The Branch Manager IN CONSIDERATION of your, Insert here the names ofthe claimants paying or agreeing to pay us, ‘The sum of Rupees. standing at the credit of Saving Bank / Current / R.D Account No. etc. with your Bank in the name of Shri/Smt./Kum. since deceased, without production of Letter of Administration or a Succession Certificate to his/her estate, we Insert here the Names of the suretly/ies, do hereby for ourselves and our heirs, legal representatives, executors and administrators, jointly and severally UNDERTAKE ‘AND AGREE to indemnify you and your successors and assign against all claims, demands, proceedings, losses, damages, charges and expenses which may be raised against or Incurred by you by reasons or in consequence of your having agreed to pay /or paying me/us the said sum as aforesaid. Signed, Sealed and delivered by the above named on this dayof, ‘two thousand, . ‘SIGNED AND DELIVERED by the above named 4 (Heirs/claimants of the deceased) ‘SIGNED AND DELIVERED by the above named 1, 2. (Sureties)