/ANNEXU! CANCELLATION REQUEST FORM re cnet Executive omer re eee tse . "eh conn HAJ-2024 T-A, MLR.A. Marg (Palton Road), Mumbai - 400 001. COVER NO. sr Its requested to cancel the pilgrims listed below and grant admissible refund amount. DETAILS OF PILGRIM (S) TO BE CANCELLED TREASON OF CANCELLATION PLEASE TICK ())ARY ONE =] ve ro wea [$5 [ passeort no] wAME OF THE CANCELLED paLcramy| DEATH) MEDICAL rmanciat[oomesTicfoTHERs UE aN 1 2. 3 4 Claim |Copy of Pay| Medical /| Copy of front page of bank | Any Other (Please Specify)| ENCLOSURES| Letter | insip | Cerificate |passbook/cancelled cheque Please tiek (1 ) In case of Death, details of Nominee as per Haj Application Form Name Relation BANK DETAILS OF NOMINEE (attach copy) Tame of he Branch he] Bank Name Branch Name | R81 pecounta. | IFSC Code || We certify that the particulars given above are true and correct. Date Place: Signature! of cancelled pilgrim(s) Itis certified that the particulars mentioned above are correct and as per entries in the Haj Application Form (s). It is recommended that the Haj application of above referred pilgrim(s) may therefore be cancelled. Date Executive Officer ace: State / UT Haj Committee Forward to: - Haj Committee of india, Haj House, 7-A. MRA. Marg, Mumbai-400 001. Fax No. (022) 22820020 / 22830481