Claim Application Form

IaI 34y f2/Claim Request Date:16-08-2023

fga Hatg/43eI,/ Dear Sir/Madam,
À, q AT4/|, Full NameSANJUKTA SAHOO

fgai/qf i HI4/Father/Husband Name:

Sign across the

photo
Date of Birth:17-05-1976, do hereby apply for a claim against my
deposit(s)/ contribution (s) amount which is to be credited to my following Bank :
1HJH/Bank Name: STATE BANK OF INDIA

Following are my deposit details:

Membership Certificate/ Account Deposit

Claim Society Account No. Receipt No. Deposit Loan Loan
No. Passbook No. Opening Contribution
No. Code Partially Amt Repaid
Date Amount
Repaid

28-06
HICCSL611798001357|11797402829|665036411813438000795966 2018
10800 0

qU/ Declaration

ÀSANJUKTA SAHOO VAEI qUI EAI fi Humara India Credit Coperative Society Limited, uAt . 1 E

H t à a Ht MAf |34d aHRTA/ HKTÍRrA| R G Humara India Credit Cooperative Society Limited. aaf

829DEFE67DC3F79AD989A50C9A00COBA Page No. 1 of 2

 1. SANJUKTA SAHOO hercby declare that I am a
Cooperative Society Limited,_Society Ltd. and have genuine depositor/member of Humara India Credit
details given above in this made legitimate deposits in this Society as per the
above Societies in all the
application form, Ihave aiven details of all the
Schemes. The aforesaid information given deposits made by me in the
of my knowledge and above is true and correct to the best
belief and | have provided true proof of
were made by me in the my deposit and claim. The said dep0sit(s)
Humara India_ Credit Cooperative
legitimate income before 22.03.2022 in case of Society Limited, Society Ltd. out of my
Sahara Credit Cooperative Society Ltd.,
Saharayn Universal Multipurpose Society Ltd., Lucknow.
Bhopal and Humara India Credit
Kolkata and before 29.03.2023 in case of Stars Cooperative Society Ltd.,
compliance with relevant Income Tax Laws.
Multipurpose Cooperative Society Ltd., Hyderabad and in

2. If any of the information

given by me in the above application form is subsequently proven to be
incorrect or false, I hereby undertake toreturn the refunded amount along with the
applicable interest to
'Sahara-CRCS Refund Account' and indemnify the "Sahara CRCS Refund
shall also not pursue the claim in other forum to
Account' to the said extent. I
the extent it is settled by the
Account'. 'Sahara-CRCS Refund

3.Further, I shall also be liable for any civil or

criminal action in accordance with law, in case of any
falsehood or misrepresentation.

ata/Date: 16-08-2023 GHGaÍ I BHAT/Signature of Depositor:

Sent ta..aoo
qAA/Place:..."
BBS.R.
GIH|ehdi H A/Name of Depositor: SANJUKTA SAHOO
egg 4/ Mobile No:

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