Annexure - 4

Application for deceased claim

( To be used for cases other than nomination /joint account with survivor clause)

From
______________________
______________________
______________________

To,
The Branch Manager
Uttar Bihar Gramin Bank
____________________ Branch

Dear Sir,

Reg. :: Deceased account late Sri Smt. ………………………………A/c No.(s)………………….

I /We advise, the demise of Sri /Smt. _____________________________ on ___________.He

/She holds the above account(s) at your branch. The account is in the ………………………..
names(s) …………………………………….. of …………………………………………….

I/We lodge my/our claim for the balances with accrued interest lying to the credit of the above
names deceased who died intestate. I/We am /are the legal heirs of the above named deceased
and lodge my /out claim for payment as per the bank’s rules and discretion. The relevant
information about the deceased and the legal heirs are as under : -

1. Names in full of the parents of the deceased :

Father :: …………………………………………………………………………………………

Mother :: ………………………………………………………………………………………...

2. Religion of the deceased : ____________________

3. Details of living (i) Husband (ii) Wife (iii) Children (iv) Father (v) Mother (vi) Brothers
(vii) Sisters (viii) Grand Children. If Hindu joint family, the name and address of the
karta and Co-parceners with their respective ages.

Full Name/Address Occupation Relationship with deceased Age

1. _____________________ __________ _________________ ______
2. _____________________ __________ _________________ ______
3. _____________________ __________ _________________ ______
4. _____________________ __________ _________________ ______
5. _____________________ __________ _________________ ______
6. _____________________ __________ _________________ ______

E:\RAO\OPR\Complain\Annexure - 4.doc
4. Name or names of Guardian/s
Of the minor, Children of the depositors ____________________________________

(a) Whether Natural Guardian

(b) Whether Guardian appointed by Court of Law in India. If so, attach a certified copy or
duly attested copy of such order ________________________________

(c) In whose custody the Minor/Minors is/are ?

5. Claimant/s name/s and address in full

i. _________________________________________________________________
ii. _________________________________________________________________
iii. _________________________________________________________________

I/ We submit the following documents. Please return the original death certificate to us after
verification.

1. Death certificate (original +1 photocopy ) issued by

2. Letter of indemnity

We request you to pay the balance amount lying to the credit of the above named deceased
to ……………………………………………………………………………………. on my/our
behalf.

I/We hereby solemnly affirm that the above statements are true and correct to the best of my/our
knowledge and belief.

Place : Yours faithfully,

Date :

Signature of claimant (s)

Name of claimant Address Signature

E:\RAO\OPR\Complain\Annexure - 4.doc
 Annexure – 6
Indemnity format ( To be duly stamped as per the stamp act
(for claims upto threshold limit Rs.25000/- applicable to the state.)

To be executed by all the major legal heirs of deceased and two

sureties of the substantial worth.
To,
The Branch Manager
Uttar Bihar Gramin Bank
____________________ Branch

Dear Sirs,

Reg. :: …………………………………..……….A/c No. …………………………….… in the

name of ………………………………………………….

01. We regret to inform you that Shri/Smt./Kum. ___________________________Who was

maintaining the above ______________ account No. ___________ at your _____________
branch in his/her single name, died intestate at ______________ on ___________________.

02. We have further to inform you that he/her left behind him/her surviving as his /her only heirs
and next-of-kin the following
i. ……………………………………..
ii. …………………………………….
iii……………………………………..
iv……………………………………..
according to the law of Intestate, applicable to __________________ by which law he/she was
(Hindu, Muslim, Parsi etc.) governed at the time of his/her death.

03. We have further to inform you that the balance standing to the credit of the ______________
Account No. ________________ is Rs._________ in the name of the said deceased.

04. We have therefore approached you with a request to pay the aforesaid sum lying to the credit
of the ___________ Account to the undersigned Smt./Shri ___________________________
(Name of the person whom to pay/handover) (The person should be from amongst signatories
only)

On our behalf without insisting on production of legal representations and you have kindly
agreed to do so on our executing an indemnity as is herein contained and on relying on the
information herein given by us and believing the same to be true.

E:\RAO\OPR\Complain\Annexure -6.doc
05. In consideration therefore, of your having at our request agreed to pay the balance standing to
the credit of the aforesaid account to the undersigned _________________________________
we, the undersigned (Name of same person whom to pay/handover) _____________________
____________ ________________ _________________ _____________________________
(name of heirs & next of kin ) and _______________________________ ________________
hereby jointly and (name of two sureties)

Severally agree and undertake to indemnity and keep indemnified, saved, defended, harmless
you and your Successors and Assigns for all times hereafter against all losses, costs, claims,
actions demands, risks, charges, expenses, damages, etc. whatsoever which you may suffer and
or incur by reason of your at our request paying/handing over as mentioned hereinabove to the
undersigned _____________________ the aforesaid balance of Rs. _______________ standing
(name of same person whom to pay/handover) to the credit of the aforesaid account without
insisting on production of legal representations.

Yours faithfully,

NAME OF HEIRS & NEXT OF KIN SIGNATURE

1. _______________________ ________________
2. _______________________ ________________
3. ________________________ ________________
4. ________________________ ________________

NAME OF SURETIES/ADDRESS SIGNATURE/DATE

1. ________________________ _________________

2. ________________________ _________________

E:\RAO\OPR\Complain\Annexure -6.doc
 Annexure – 7
( To be duly stamped as per the stamp act
applicable to the state.)

Declaration of oath

We, Shri/Smt. _________________________________ residing at ____________________

do hereby solemnly affirm and state as under:

1. That Shri/Smt. ________________________________________(name of deceased) the

husband/wife of the above name deponent Shri/Smt. _________________________ and the
father/mother of ________________________________ the above named deponents, died
intestate at ____________________ on ______________

2. That he/she left behind him/her surviving the following persons as his/her only Heirs
according to the Law of intestate Succession applicable to ____________________ by which
Law (Hindu, Muslim, Parsi, etc.) he/she was governed at the time of his/her death :-

SN Name of the heir Address Age Occupation Relationship with the

deceased
a.

b.

c.

d.

e.

f.

3. That the said _________________________________________(hereinafter Unless expressly

named or otherwise distinguished for brevity’s sake called “the deceased”) maintained ________
Account No. ______________ with Uttar Bihar Gramin Bank at its________________________
Branch in his/her single name.

4. That no letters of representation to his/her estate have been obtained or are contemplated to be
obtained.

5. That Rs. ______________________ is the amount due and payable to the deceased by Uttar
Bihar Gramin Bank being the balance standing to the credit of the aforesaid account.

E:\RAO\OPR\Complain\Annexure -7.doc
6. That the deceased has not left any debts and no amount is due to Uttar Bihar Gramin Bank
from him/her and that in the circumstances mentioned above, the above named deponents are the
only persons entitled to the amount standing to the credit of the aforesaid
________________________ Account and no other person is entitled there to or to any part
thereof.

7. We hereby further state that we know that relying on the above representations and believing
the same to be true, Uttar Bihar Gramin Bank has agreed to pay the aforesaid sum being the
balance standing to the credit of the ___________________ Account to the above named
deponents, without insisting on production of legal representations.

Solemnly affirmed by the )

Above named deponent at )
On the _____ day of _______ )
20 ____ in the presence of: )

E:\RAO\OPR\Complain\Annexure -7.doc
 ज ाँच प्रतिवेदन

मत
ृ क खाताधारी के उत्तराधधकाररयों को भुगतान हे तु जााँच अधधकारी द्वारा ककया जाने वाला जााँच
प्रततवेदन :-

1. मत
ृ क खाताधारी का नाम :-

2. मत
ृ क खाताधारी के पिता/ितत का नाम :-

3. मत्ृ यु की ततधि एवं मत्ृ यु प्रमाण ित्र संख्या :-

4. मत
ृ क खाताधारी का स्िाई िता :-………………………………………………………………………………………………………………………

5. मत
ृ क खाताधारी का वततमान िता :-…………………………………………………………………………………………………………………….

6. मत
ृ क खाताधारी के घर से सम्बंधधत बैंक शाखा की दरु ी :-

7. मत
ृ क खाताधारी के तनवास स्िान की चौहदी िर ककनका मकान है :-

उत्तर - दक्षिण -

िूरब - िश्चचम -

8. वंशवि
ृ (यदद मत
ृ क की दो शादी है तो दोनों शादी के ितत/ित्नी के नाम सदहत सभी ित्र
ु / िुत्रत्रयों
के नाम, उम्र, िे शा, तिा वततमान में कौन कहााँ रहते हैं का िूणत पववरण) :-......................................
......................................................................................................................................
......................................................................................................................................

9. दावेदारों (उत्तराधधकाररयों) के बीच क्या दावा राशश के संबध

ं में ककसी प्रकार का पववाद है :-
10. मत
ृ क के द्वारा क्या नामांकन ककया गया है (िण
ू त पववरण दें ) :
11.(क) जमा खाता का प्रकार :- (ख) जमा खाता संख्या :-

(ग) जमा खाता में वर्णतत राशश :-

12.वततमान में मत
ृ क खाताधारी के उत्तराधधकाररयों के नाम , व्यवसाय एवं है शसयत का व्योरा :-
1.
2.
3.
4.
5.
13.जमानतदारों के संबध
ं में िण
ू त जानकारी :- (बैंक द्वारा तनधातररत पवत्तीय प्रततवेदन संलग्न करें )
नाम िता खाता/खेसरा संख्या है शसयत
1.
2.

14.जााँच अधधकारी का जााँच के क्रम में सस्

ु िष्ट मंतव्य :-
मत
ृ क ............................वल्द ...................................ग्राम ................िोस्ट ................के रहने
वाले िे श्जनकी मत्ृ यु ददनाक .........................को हो गई | इनका ..............खाता हमारे शाखा में
ददनांक.....................को खोला गया िा श्जसमें ददनांक ...................को जमा शेष रुिया ..................... है |
मत
ृ क खाताधारी के उत्तराधधकारी क्रमशः....................................................................................
........................................................................................................................... हैं | मत
ृ क खाताधारी
के जमा शेष को िाने हे तु दावा संबध
ं ी कागजात बैंक शाखा में जमा करा ददए गए हैं | दो जमानतदारों ने
जमानत स्वरुि अिने हस्तािर ककये हैं एवं उनकी है शसयत ददए गये साक्ष्य के अनस
ु ार सही िाया गया है |
स्िानीय तनरीिण के क्रम में यह जानकारी शमली है की इन सभी द वेद रों के आल वें अन्य कोई द वेद र नही
है |
अतः उिरोक्त तथ्यों के आधार िर श्री/श्रीमती...........................H/O/W/O/S/O/........................ग्राम
........................श्जन्हें मत
ृ क की जमा राशश रु...............................को प्राप्त करने हे तु सभी दावेदारों द्वारा
अधधकृत ककया गया है ,उन्हें खाता संख्या .................................में शाखा/िेत्रीय कायातलय/प्रधान कायातलय से
स्वीकृतत शमलने के िचचात ् जमा ककया जा सकता है अिवा उनके नाम का चेक जारी ककया जा सकता है |
त्रबना सक्सेशन सदटत किकेट शलए इस खाते की राशश का भग
ु तान मख्
ु य दावेदार श्री / श्रीमती
.............................को दे ने की स्िष्ट अनश
ु स
ं ा की जाती है |

जााँच अधधकारी का नाम :-

जााँच अधधकारी का िद नाम :-
जााँच अधधकारी का हस्तािर :- शाखा प्रबंधक का हस्तािर
जााँच की ततधि :- शाखा का मोहर
 Date :: ………….
Letter of disclaimer
( Properly stamped and notarized )

Branch Manager
Uttar Bihar Gramin Bank
____________________ Branch
____________________ District

Reg.:: Payment of balance of Deceased A/c of …………………………………….…………..

S/o …………………………………………. HSS A/c /TD A/c No. …………………………..
For Rs…………………………………… +Interest there upon …………………………….

Dear Sir,

With reference to above account, we the following legal heirs of late ……………………..
(deceased ) have to declare that we have no interest in the above assets /amount and as such we
have no objection for your paying the balance amount lying in the above said account with you
in the name of deceased account late …………………………………………………..……. to
Sri /Smt. ………………………………………………………….. Husband /Mother/Wife/Son.
The making of payment of the balance of above said account will be completely binding upon us
and we shall not make any question for the Bank action in doing so, in any proceedings. We also
undertake to bind ourselves, our heirs and legal representations and not to revoke this declaration
(deceased) made herein.

Yours faithfully,

Name of Legal Heirs Signature of Legal Heirs

01.
02.
03.

E:\RAO\OPR\Complain\Letter of disclaimer.doc
 RECEIPT

Received with thank from Uttar Bihar Gramin Bank, ………………………………

Branch, a sum of Rs. …………………………. (Ruppes …………………………
…………………………………………………………………………. only) by
Banker’s Cheque No. ………… Dated : …………………. In favour of ………
………………………………………………………………………… in full and
final settlement of my/our claim as successor on the balance in ….....................
Account(s) No. ………………………………………… standing in the name of
the deceased Shri/Smt/Kr/ ………………………………………………….. I/We
do not have any other claim from the Bank henceforth.

Place :

Date:

Signature of all the legal heirs over a

Revenue stamp

Declaration in case funds are settled in favour of a Minor

I, …………………………………………………………. Father and natural
guardian of ……………………………….. hereby certify that the proceeds of
your Banker’s Cheque no. ………………… Dated :……………………..
favouring …………………………………………………… issued by you in
settlement of the balance in account number ………………………………………
of Late ………………………………………. Will be utilized for the benefit of the
minor only.
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