Claim by Nominee, Department of Post, India

DEPARTMENT OF POST, INDIA OFFICE OF THE CHIEF POSTMASTER,

GPO

To, The Postmaster ______________ ______________ Sir, The payment of ________________________________ balance at the credit of savings/SB/ TD/CTD/MIS/PPF A/C No. ___________________________________ • Payment of the value of the Post Office Certificate details below :A. List may be attached separately, Sl. No.

Cert. No.

Fee Value Rs. Regn. No.

Post Office

1 2 3 4 5 Total • In support of the claim I/we hereby submit : a) The Pass Book A/c No. : Type of A/c : Post Office : b) Photostat copies of the Savings Certificate : • Death Certificate of the Depositor a. Name of deceased (Block Letter) ________________________________ b. Date of Death ______________________ • Certified of death of the other nominee(s) if any the nomination was registered at Post Office under nomination Regn. No. Date of Nomination ________________________ Yours Faithfully (Signature of claimant) Name (In Block Letter) ______________________ Address __________________________________ _________________________________________ _________________________________________ The claimant is known to me personally and the above statement has been signed in my presence Witness 1 : Signature : ___________________________ Name _______________________________ Address _____________________________ ____________________________________

Witness 2 : Signature : ___________________________ Name _______________________________ Address _____________________________ ____________________________________