1/2014 LOAN FORM exe Soma Form No. 29 Sime Bo. 29 Inward No. woes Bo. Office Use Only wrengeahig a8Simgo DIRECTORATE OF INSURANCE BOLCS UF wainyeS) GOVERNMENT OF TELANGANA ‘Boome Bessss HYDERABAD Beso District Insurance Office gr Bie werguate + APPLICATION FOR LOAN essen S80 Sere Poligy No, bess ] 1. Name ofthe Subscriber somrertid eo 09 $0 2 Designation s*=~ eae aie 4 Date of Birth es 38 D]o] mm] ¥[¥] ¥]¥ (As per Service Register) 1 eo Hi Office where he semployed _adtzh 9 dainioiy wengeoto es D.D.0.Code 8.8.6.5 TTI TT TT 11 I | Li {The Amount of Loan applied for dewey tars, ase Togo f 2. Tha Number of Inetalmants tn which tha Loan a proposed tobe repald 1). CHE a (Not exceeding 48, according to Rule 46) i foe Rage O88 DBowdeds ONES cesere Soyy (aANED 4s Gade M8 meneres Rovere) 8 Basic Pay save Setsot Pay Scale Sip Sye0 9. Gross Salary € Total Deductions ¢ | [———)Net Salary © ace ge Ce tee seas” [___] Jo. Monthly Premium Beis (tects Rago . 11. Name ofthe Bank where Payment of Loan is desired 50 Bogss Bok Heiss, ange o> Branch Name wrod bo a 1FS cope * 25 sh 5 Bank AccountNo.* —sxgeyre soos [ * Enclose First Page ofS. B. Account Pass Book (Xerox Copy) (Contd - 2) Visit Our Website : www.tsgli.telangana.gov.in12, Employee I. D. No. astyh 28 Bones 12, Aadhar Card No. wo5 nf Boos I I 14. Mobile No. BBE Boos I 15. E-Mail of Policyholder aruborbd a - Smond 16, Mobile No. of Drawing and wren sstaim ning werd SBS Bones Disbursing Officer 17, E—Mall of Drawing and winds Sstots nings wgme M1 - Saad Disbursing officer hereby declare that the particulars stated above are true and correct. BP BOBS Btwn, SBsESD omaredam Hbwonerys. hereby authorise the Director of Insurance, Government of Telangana to pass orders to ‘effect recoveries of Loans and Interest from my salary in the manner as may be prescribed by him in ‘accordance with the Rules of Fund. 08 baw we Dabine teorde, bis we BBxS DfRods bast shat o> exe Boezdy or do to08 80h sisres Hoth aio aigenges end Habards Boome Getdy bin we BELLS wor, Date Signature of Applicant 38 Sdprigeresd Sods {Lis certified that the particulars stated in the above application are correct to the best of my knowledge and belief and the above Signature of Sri is signed in my presence. He obtained a Loan of = from TSGLI out of which © is stil outstanding. B ceynget BEDS Dios mw TOIosEEs Ltats DAyeOs hes ABLSD emowssneder aybttorocsnyss, & B deny B destin or dtgdne! Ge, sas bie wy s08 soot & nis Sodyrrys. s Bayo 08 exer Bposedssye. ‘Signature of Drawing and Disbursing Officer with Sea and Date ire Stat airy bed Sostis, 8 morgen aosat Date Name : {in Block Letters) ee bee (Contd - 3) Visit Our Website : www.tsgli.telangana.gov.inTay. Revenue Stamp ‘Pauny Se STAMP RECEIPT Note: Ifthe Amount exceeds © 5,000/-, Revenue Stamp shall be affixed. fas4 + Be © 5000/- ow Eobisyand pos eBtomd Policy No. dob Bond r have received a sum of © (Rupees ‘Oniy) from Directorate of insurance, ‘Telangana, Hyderabad vide Cheque / Online Payment No. ‘dated towards sanction of Loan / Settlement of Claim against my Policies. Bf geass is dds Base wy Bete, Jreoene we sod z eroeses soy det ‘Benes te 38; | oS BS Bod oye eecsPsyee socsinoism thes woddgoyss. Signature carren hereby certify that the above Signature of Sri / Smt. ts made in my presence. b/ bse bs B sossts ow sioginet Sed aabtbowsssanyss. Station : Signature of Drawing and Disbursing geet Officer with Seal wide Stain mings be Sosliss ropens dost Date: Name: Bet ter Designation : Visit Our Website : www.tsgli.telangana.gov.in