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:______________________ |
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.
No. | Nature of Deposits | Account No. | Amount * | Date of Maturity | Nature of Liability to the Bank, if an | Amount |
---|---|---|---|---|---|---|
${accountsObject?counter} | ${accountsObject.typeOfAccount} | ${accountsObject.accountNo} | ||||
Total Amt. | Total Amt. |
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.
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)
(If the space provided is insufficient, please use additional sheet)
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) |
Sanctioned payment of Rs. _____________________(Rupees._______________________)in accounts of late___________________________________________to claimant(s).
Place: ________________________ Date: ________________________ |
Signature |
Name: ________________________ Designation: ________________________ |
|
(Sanctioning Authority) |
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) |