(1)
To,
The
Post Master,
_________________________________________
Sir,
In connection with the settlement of claim of Post Office Certificates
standing in the name of deceased
___________ ________________________________________ in the books of
________________________________( name of Post Office ), I hereby claim the
payment of the value of the Post Office Certificate(s) No
_____________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________
In support of the claim, I hereby submit :
(i)
Proof of Death of
the deceased issued by appropriate authority in original.
(ii)
Proof of Death of
other nominee(s), if any issued by appropriate authority in original.
The nomination was registered at ________ ________________ ___ _______________________________ Post Office under
Registration No(s)_________________________________________
_____________________________________________________________
Dated
________________________________________________________
Yours Faithfully,
_______________________________________________________________________________________________________________________________________________________________________________________
Signature or Thumb Impression
of the Claimants if illiterate
Witness (1)_____________________(
Signature)
Address
_________________________________
________________________________________
Witness
(2)______________________( Signature)
Address
_________________________________
________________________________________
(2)
Witnesses accepted,
____________________
__________________________
Signature of Sr
PM/PM/SPM Signature of the
Claimant/ Guardian appointed
to receive the amount on behalf of
minor nominee(s)
Address of the Claimant/Guardian
____________________________
____________________________