Annexure-1

Application Form for Settlement of Claim of Deceased Constituents/Missing Depositors for payment of balances in accounts (To be used when account has nomination or is a joint account with survivor clause)

Bank: ${bank}	Branch: ${branch}
To, The Branch Manager,	Address for correspondence Shri / Smt / Kum: ______________________ Address: ______________________ ______________________ Contact No:______________________ Email ID: ______________________ Date:______________________

Madam/Dear Sir,
Claim for Payment of balances in the account (s) of Late/Missing Shri / Smt / Kum. ${deceasedName} expired on ${dateOfDeath} is missing from ________________ and is not traceable.

I / We advise that Shri / Smt/ Kum ${deceasedName} was maintaining following Accounts at your Branch:

<#list accountsObjects as accountsObject>

No.	Nature of Deposits	Account No.	Nature of Liability to the Bank, if an
${accountsObject?counter}	${accountsObject.typeOfAccount}	${accountsObject.accountNo}




	Total Amt.		Total Amt.

*(the actual amount of claim with accrued interest will be worked out on the date of payment.)

A. In case of Nomination

I, ${nomineeName}_______ son/daughter of Shri ${deceasedName}________ Residing at ________________________________________________________ am

The registered nominee in the above account(s)
The person authorized to receive monies on behalf of Master/Miss ${claimantName}________

who is the nominee in the above account(s) and is a minor as on the date of the claim.

Please arrange to settle the claim in the name of the nominee. l/ We have shall receive/ received the payment as trustee of the legal heirs of the deceased / missing person.

B. In the case of Joint Account

l/We are the Survivor(s) in the above account (s) opened jointly with deceased / missing person with mode of instructions.
_____________________________________ Please arrange to settle the claim / continue the account in the name of Survivor(s).

C. Document Submitted for Verification:

l/We submit photocopy of the document(s) and original documents for verification towards the settlement of claims.

Document for Settlement for Deceased Constituents:

Original Passbook	Death Certificate
Original Fixed Deposit Receipt	Identity proof of claimants
Unused Cheque / ATM etc.in the accounts

Document for Settlement for Missinq Depositors:

Original Passbook	Identity proof of claimants
Original Fixed Deposit Receipt	Copy of FIR lodged with Police authority
Unused Cheque / ATM etc.in the accounts	Certificate issued by Police authorities that such missing person is not traceable
The report of non-traceability of missing person by the Police should be of a date after 7 years from the date of registration of FIR and enquiry the Police authority	Declaration by the Nominee /Legal Heirs of the missing person/depositor that the missing person has not been heard of for the last seven years
Order from competent court presuming missing person as deceased / Death certificate from competent authority( wherever required)

I / We also understand that i/we will be required to produce all documents desired to establish my/our claim till settlement and agree to execute the required documents to settle the claim as per the bank's process & policy

I/We declare that the facts stated above are true and correct to the best of my/our knowledge and belief.

The amount of claim settled including up to date applicable interest may kindly be issued Banker's cheque/ credited to the account standing in the name of_____________________________________ S/D/W _____________________ maintained with __________________________bank__________________________ Branch in India.

Signature (s) of the claimant (s) who will receive the claim amount

<#list claimantObjects as claimantObject>

Sr No.	Name of claimant	Signature
${claimantObject?counter}	${claimantObject.claimantName}

Place: _____________________________

Date: _____________________________

Encl: As above.
(Two Bank acceptable witness is required in case of claimants(s) are illiterate)

Note : The Bank is not responsible for any delay in disposal of the claim due to lack of full particulars furnished in this application and may insist on calling for a Legal Representation in case there are disputes among the claimants & all of them do not join in indemnifying the Bank (Or give letter of disclaimer) or where the Bank has reasonable doubt about the genuineness of the claimant(s) being the only heir(s) of the deceased customer.
(If the space provided is insufficient, please use additional sheet)

FOR OFFICE USE

Recommendation :

I have made necessary inquiries about the claim made by the nominee / survivor(s) & satisfied that the claim can be settled. All the necessary documents have been obtained. The claim may be paid to the nominee / survivor(s).

Any other remarks:

Place: ________________________ Date: ________________________	Signature
	Name: ________________________ Designation: ________________________
	(Recommending Authority)

Sanction:

Sanctioned payment of Rs. _____________________(Rupees._______________________)in accounts of late___________________________________________to claimant(s).

Place: ________________________ Date: ________________________	Signature
	Name: ________________________ Designation: ________________________
	(Sanctioning Authority)

Disbursement & Record:

Amount of Rs. _________________________________________(Rupees.______________________________________________) paid by way of.

Banker's cheque No.___________________________Dated_______________and receipt obtained.

Credited to claimant's Account No___________________________ maintained with _________________________Branch and copy of statement of account carrying the relevant entry maintained on record as part of the claim settlement.

All the documents pertain to this claim settlement have been kept on Branch record.

Place: ________________________ Date: ________________________	Signature
	Name: ________________________ Designation: ________________________
	(Disbursing Authority)