AFFIDAVIT

(Affidavit certified by a Notary to be produced by Applicant for his/her name mismatch

between Aadhar and Society’s FD Certificate/Pass-Book for the purpose of Resubmission of
Application on CRCS-Sahara Refund Portal (Resubmission)Please type or Use Capital
Letters for legibility while filling up details)

Phot
o

I, MANSA S/O CHHIDU, DoB 01/01/1977 residing at G - 334, BLOCK - G, J. J. COLONY,

SAVDA, NORTH WEST DELHI, DELHI - 110081 (Present address) and permanent
address SAME AS do solemnly affirm and state as under:

1. That I am the citizen of India.

2. That my name in Aadhaar is mentioned as 6771 1186 3807.
3. That I am a member of

Name of Society Membership Number

i) SAHARAYN UNIVERSAL 945088000614
MULTIPURPOSE SOCIETY LIMITED

4. That my name as in the FD Certificate(s)/RD Pass-Book(s) of the above

Society(ies) is mentioned as MANSA RAM.

5. I, hereby declare that above names pertain to one and same person i.e. the
Deponent being both the account holder and the member of the Society;
and for confirmation of above fact, I am attaching a self-attested copy of
my Photo ID i.e. PAN Card and ADHAAR Card.

6. If any of the information given by me in the above is subsequently proven

to be incorrect or false, I 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.
 Signature
(Deponent)
Verification

Verified and I solemnly state that the contents of this affidavit are true to the best of my
knowledge and belief and that nothing has been concealed therein. Further, I shall also
be liable for any civil or criminal action in accordance with law, in case of any
falsehood or misrepresentation.

Signature
(Deponent)
Place:
Date:

Signature of Notary Notary Seal

Name of the Notary

Registration ID No.
Address