I

st Date 2 9-0 I - 20 2 3
m Req ue :

ei'fl sdi?r ftlialC a

t i

Bq qfi-{q/q+fl ,/ Dear SirlMadam' .fr sar

t, qsr qmll, Full NameNarendra Gochhyal

ftallcft *r i,IqlF atheri Hu sband trt ame @ lalcl q( ltflql( qr( I

{s* gK R ft.{ftGatt.*
i
sql41sii Sign across the
e-rq 61aifts:01-0't:1958'
ft-fls } fts arrt-fi 6t :- Photo
ffd tS Ecl({rftS')lr'iscnt{rft) k
Era
a claim against my
of Birth:0'l-01-:195&' do hereby appty for
Date
deposit(s)/contribution(s)arnountwhichistobecreditedtomyfotlowingBank:

?o qr qrslBank Name:

t'S qe1 nft er fr'q{'l ffifrat

details:
Following are mY dePosit qql
qifrr++t{ fisI
yqrsrqdlcls{+ t q+rsr 1-dlql
{SE il tl
M q-{{q-o {.1
a.l aft*ftt rr{[ tl rrqr

6tsl €rdl iffi-l +i@r./

Certificate/
DePositl
Deposit Loan
i@I.l
Account No' Passbook artial
No- Amount {
Code RePaid
t

118812193 17951CI1047

dtqw / Declaration

qql*-d BiT ftsr qr-{rt

Limited. ffi fr,

ft t *unu.., C,*dit Cooperative-SocietY qm ftqi ?
t Narendra Gochhyat {nEI.. *qEI 6ftr { t sqr ftq rrq fi-q{ur h
q-wu qs qftft t *q r }t

an {u, s*r*r* vq.rqatft-d{q E

*i tt 5u art-q+ sq-d

Page No' 1.-of 3

sctefiilrloiogsscepsza2gToTcFEED
=
Ecfd qRft qt qS +ffrS t lt gru qqr qff T{ q,ff sqRTM *r ft-+rq frvr t r sq-St-a e-<d
{ffi tS sfu
',c-*r6
fr{iflq t sqq 3h a-$ t afu tt ect qcr sfu dI} *.r q-$ srw frcr t r rw qqmRrlqqTeftqi ft gnr sahara credit
Cooperative Society Limited. uffi t ft tsi 3{-q * rsru *Fc sbfrqtftq frgl-{Jt ft., os+a; s6r{r-fi
fr.
{ffia qqffiq M fr., $cr-f, $l wnr iftqr *fte Efufrctfuq M fr., *toqrar e,l <qlr t ftqi6
22.03.2022 * q-{A 3fu wIS q-dffiq *bfrctkd M ft., tflrqr qft q$ t friin Zs.al.zuza h q,-A +{
€-{ft-d sir{r+-{ mrta } iil{ct${ t ftqT.rqrt r

1' Narendra Gochhyat hereby declare that lam a genuine depositbr/memberof Sahara
Credit
Coqperative Society Limited, Society Ltd. and have made legitimate deposits in this Society
as
per the details given above in this apptication form. I have given details
of all the deposits
made by me in the above Societies in all the Schemes. The aforesaid information given
above
is true and correct to the best of my knowledge and belief and I have provided true proof
of my
deposit and claim. The said deposit(s) were made by me in the Sahara Credit Cooperative
,- Sqciety Limited. Society Ltd. out of my legitimate income before ZZ.0S.2OZ2 in case of Sahara

Credit Cooperative Society Ltd., Lucknow, Saharayn Universal Multipurpose Society Ltd.,
Bhopal and Humara lndia credit cooperative society Ltd., Kolkata and before
2g.03.2023 in
case of Stars Multipurpose Cooperative Society Ltd., Hyderabad and in compliance
with
relevant lncome Tax Laws.
pl'

2. qfr ft ara aq{-{a 31[}dq c{a t

fr 'r{ q}'$ rff {F{r sE t .rsd qr fte{qr srftd E1-ff *, fr t Entqqrq {er s.kd ff*-s
qfr {Tfrr 'uuu-frer$gs f i;s srat' t qrs{ s{t ${ 'uuc-frunfiqr rl.[:e u'rar, t rqd {Tft eff qift{ffi u,.1 u,1
{FdqqT +-{aT { tt 'vanr-d3T{d\rv rtis e-ril' 6xr jffi.r{ e1-qr-{|-ft *1dqr a-* *.Era 41 ffi arqq q-q t Td?
B-d[irrr/s-drii=ft l.

2' lt any of the information given by me in the above application form is subsequenly proven to
be incorrect or false, I hereby undertake to return the refunded amount along with the
applicable lnterest to 'sahara-CRCS Refund Account' and indemnify the ,,Sahara CRCS
Refund Account' to the said extent. I shall also not pursue the claim in other forum
to the extent
it is settled by the 'sahara-CRCS Refund Account'.
+* 'i:
3. gq& aftrqo, ffi ars-{+dr qr ftwr-e-silff *1 <rn t mrtq ar q-dsl{ ffi,#h#fo 3{c$ft-d q1qq i-{ t gfiErS fi
r{-,nl is
'&u
3. Further,.l shall also be liable for any civil or criminal action in accoffi,&e with law, in case of
any falsehood or misrepresentation.

,,In s)-frral
,"y.
rf,ry
qqrs-dt qr rqdr$Vsignature of Depositor:
arSs/Date: 29-08-2023

5CE87561 E2636355CEF52829707CFEED Page No.2 of3