waa satu Gare/Claim Request Date: 25-11-2023 fir nitgumeu/ Dear Sir/Madam, qu rari, Full Name Chandrika Prasad fravatt mt aiiF ather/Hushand Name S/O Ram Khilawan sere nn 1068. pe pr Be Ree tet ae wd soed ary eerste wt ly sat? Date of Birth: 1963. do hereby apply far a claim against my eposit(s}! contribution(s) amount which is to be credited to my following Bank -» Sign ncrozs the photo ‘rw =n/Bank Name: UNION BANK OF INDIA ‘tof won off wr ary Faftina ?- Following are my deposit details - wa | aad |ese ‘on wa area ad jtem./| ster | ae aac) | nbc doms out Membership laimiSocietyScheme] Account| Receipt No. Lean No, | Gode | Name i No. JRepai e + foumsi| © fraizeonzese] —— fseosznosssi | 79.02 2 fos 0 fareoaeoo0ss6) jsdozzeogs47| 0 roe | 2 |e fo] o | “pen. / Declaration anne gre fier are 9 Chandrika Prasad capo teen wen ¢ ff 4 Saharaym Universal Multipurpose Society Limited, ah 2. so spores wommifrcns @ Sec BR yw sat ye 8 Rag Bare argene ya AB Sea Pe | hae oA a al stb 2 AR gre en i nk a eh on Baa an | vega weer ages AA ret ake Rega qa Sr al 8 ACA we aq fe ct oof er Ro | ser ecards R ge Saharayn Universal Multiourpoae Socinly VCSI7ASAZATERIZETTORTCESECASOFOT Page No. of 2eel ®., crete; ‘wtersdl F2., stores ate fae er ke sateen at steven ot ew Rew 22.03.2002 & WEA str and uednt skit hare M., Yeawre gan 3 Di 20.03.2025 3 wad ate wae seme EET ae Mer em | 1. Ghandrike Prasad hereby declare that | am a genuine depositor/member of Saharayn Universal Multipurpose Socigty Limited Society Lid, and have made legitimate deposits in this Séciety as per the details given above in this application form. | have given details of all the deposits made by me in the ‘hove Societies in all the Schemes. The afatasald information givan abave if true and correct to the best of my knoltledge and belief and | have provided true proof of my deposit and claim. The said deposit(s) Were made by me in the Sabarayn Universal Multipurpose Society Limited Sociciy ‘Ltd. out of My legitimate income before 22.03.2022 in case of Sahara Credit Cooperative Society Ltd,, Lucknow, Saharayn Universa¥ Multipurpose Society Lts., Bhopal and Humara india Crodi Cooperative Sacioty Lic. Kolkata and before 29.03.2023 in case of Stars Multipurpose Cooperative Society Lid. Hyderabad and in Compliance with relevant income Tax Laws. 2 aR Rn ari shes ova ate AE er we vec Fae seer 4, Ne wa ator OF Wh amratoaiey foe ara’ 8 eee cht “wearer tmx re 8 er oft «tafe mt af eden seem £1 “recat fe age Pent farm ne 8 el te Aa arse | 2. any of tne information given by me in the above applicatian form is Subsequently proven to be 'neorreat or false, I nereby undertake to return the refunded amount along with the ‘applicable interest to “Sshara-CRCS Refund Account’ and indemnify the “Sahara CRCS Refund Account’ te the said extent. 1 shail also not pursue the claim in athar forum to the extent it Is settled by the “Sahara-ORCS Refund Account’, Sor stows, fl seem «Prise a's Sega Be Rb onsuin ger ba aacend of rer, 3; Further, | shall also be lisble:for any civil or criminal action in accordance with tam, in case of any falsehood or misrepresentation. ore fy BHM/ Signature of Depositor- wet E na wg afa/Date: 26-11-2025 aPlace:.... DELIA sonal = ary/Name of Depesiior: Chandrika Prasad Maer RENE n. {2225 MRO ‘TC3174942A 1839267764 1CROECADOFET Pape Nor of >