- Appendix "A"

(/// )
/ /
NAME OF CLAIMANT/
ORGANISATION
( Surname) ( Name) (/
Father's/Husband's Name)
PAN NUMBER

POSTAL ADDRESS

PIN CODE
NAME OF THE BANK

NAME OF BRANCH & ADDRESS

BANK IFSC CODE

BANK ACCOUNT NUMBER
[ ] SB [ ] CA [ ] CC
BANK ACCOUNT TYPE

BANK MICR CODE


CLAIMANT LAND LINE NUMBER

CLAIMANT MOBILE NUMBER
-
CLAIMANT E-MAIL ID
(UID)/
(EID)
................................ .

, .
.

_____________________________________________________
/
(Name and Signature of Paper-setter / Paperset-Moderator)