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Page 5


(To be signed by an independent respectable person well known to the
deceased person’s family but unconnected with it and acceptable to the
*(Where the amount of the claim for balances exceeds Rs one lakh, the person

furnishing the declaration will have to execute an affidavit as per the format

enclosed COS 539 (Annexure – B) before a “Judge / Magistrate / Notary”

instead of the declaration. The affidavit will be stamped according to the

Stamp Act in force in the respective State.)

(o) * Names and ages of the claimants who propose to execute the Letter of
Disclaimer: -

NAME AGE (Years)









(p) * A Letter of Disclaimer as per Annexure - A duly stamped & executed is

*{Strike out if not applicable.}

(q) We propose the following surety (ies):

I) Name & address: Shri / Smt / Kum------------------------------------------------- --------

II) Name & Address: Shri / Smt / Kum---------------------------------------------------------

{The detailed information on the sureties, to arrive at their worth, is to be furnished in

a separate form Annexure – I. Sureties, who are the relatives of the deceased, may

be accepted, provided they are not directly involved as claimants and are considered

individually or jointly good for the amount involved. If one surety is considered good

for the amount by the Bank, second surety is not necessary. The sureties have to

sign the Letter of Indemnity as per format enclosed (COS 540 Annexure – C). The

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Letter of Indemnity will be stamped according to the Stamp Act in force in the

respective State.}

(I / We declare that the facts stated above are true and correct to the best of

my / our knowledge and belief.)

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

I) ------------------------------------------------------------

II) -------------------------------------------------------------------

III) ------------------------------------------------------------------

IV) ------------------------------------------------------------------

V) -----------------------------------------------------------------

VI) ------------------------------------------------------------------


{To be signed by all the claimants other than those who have relinquished
their right in the property by furnishing a “Letter of Disclaimer” as per the
format enclosed (Annexure – A) and will be stamped according to the Stamp
Act in force in the respective State.}

(Please note that the claimants will have to sign the receipt for having received the

claim amount.)

Encl: As above

{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 legal heirs & 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.



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Report of the Recommending Authority: -

I have made necessary inquiries about the claim made by the claimants & satisfied

that the claim can be settled. Surety (ies) offered are acceptable as per Bank‟s

extant instructions.* All the necessary documents have been obtained. The claim

may be paid to the claimants.

*(Strike out if not applicable)

Any other remarks: --------------------------------------------------------------------------------------

Place: ---------------------

Date------------------ Signature with date
Name & Designation
(Recommending Authority)
Sanctioned & Control Return sent on-----------------.

Place: --------------------- ----------------------------------

Date------------------- Signature with Date

Name & Designation
(Sanctioning Authority)


Disbursement & Record
Amount paid by banker‟s cheque No. -------------dated------------------- for Rs -------------



------------------------------------------------------------------------------------------- and receipt

obtained as per sanction No. --------------- dated----------------. Documents kept in

Branch Documents vide item No.------------ page No.-------.

Place: ----------------------

Date: -----------------------

Signature with date

Name & Designation

(Disbursing Authority)

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