Clain Application Form a argu RiaVClaim Request Date:13-10-2029 Sa waizamea,/ Dear Sir/Madam, +8, ATH, Full NemePrabhavali Devi ‘Ravefl 1 s/Father/Husband NameW/O: Sharada Prasad $5 Wl ta: 01-10-1963, red gra Praha eA aw — Sign across ne sl Bet ace} strra(ah & Fes 3 Hy sve =e hans Date of Birth:01-10-1963, do hereby apply for a claim against my deposit(s)/ contribution(s) amount which is to be credited to my following Bank :- ‘Se TWBank Nami 26 wa oft w fre Raat: Following are my deposit det: 7 | sii: fara atelier of} | | za | deed [aera ws aie apeany ee [88e8| a] ewe lwreas| wer | ar " arity | doy wi mae | ew rae JeinfSccityScheme| MOM | smi No Receipt Cerieate! Account} Depoaty | ™ "| © | P [Piaimocietyscheme) yo, | Aecount No Na” |Passbo0k No. fopeningkcontibution|» P00 ter _ No. | code | Name 0. ate eae. Pattaly|Amt Rea Repaid| & t et 15-09- 1 |SCCSL| 0 /17071202539]17079500087/ \755000397875| ahz0 30000 0 o ° ais / Declaration ‘sored gra Rat aT ‘wom ecee & SAH Saes ea A oe AR ne Ao A ore eT MAAN A ho fran 1 A aed aA aD en Mrs! BR gre ern wag oh ret we Pre eer veer Tea A el arene She ReeaTa A a She el BSAA oe} ee Sty Bi edi eres ert 1 sea eoravanmafel A yr Sahara Credit Cooperative Soclaty Limited, wf. 3 be sre 2 worm Bite atahitea honed @,, eras, WeTTT aed med eA @., store she err eter Bie wore ated ,, Sever wf cen A fais 22.03.2022 2 eA ste vend nelade owt dane A, Rewer wt a A Rais29.03.2023 & eed She waita are aA A angers 7 ea TR 1. Prabhavati Devi hereby declare that | am a genuine depositor/member of Sahara Credit Cooperative Society Limited. Society Lid. and have made legitimate deposits in this Society as per the details given above in this application form. | have given dotails ofall the deposits made by me in the above Societies in al the Schemes. The aforesaid information given above is true and correct to the best of my Knowledge and belief and | have provided true proof of my deposit and claim. The said deposit(s) were made by me in the Sahara Credit Cooperative Society Limited, Society Ltd. out of my legitimate income defore 22.03.2022 in case of Sahara Credit Cooperative Society Ltd., Lucknow, Saharayn Universal Multipurpose Society Ltd., Bhopal and Humara India Credit Cooperative Society Ltd., Kolkata and before 29.03.2023 in case of Stars Multipurpose Cooperative Society Ltd., Hyderabad and in compliance with relevant Income Tax Laws, 2 8 Rr swe seks wea 8 nt AY oe ae re rae 8 ame UA ah fhe od oi Revederce Ge war Bea we St rote fh wa 8 en of oa a eee me 8 ‘sereoncthe fs a gr red ch fis wR ae Hat serem/sa | Incorrect or false, | hereby undertake to return the refunded amount along with the applicable interest to "Sahara-CRCS Refund Account’ and indemnify the “Sahara CRCS Refund Account’ to the said extent. 1 Shall also not pursue the claim in other forum to the extent it \s settled by the ‘Sahara-CRCS Refund Account’, 3. eee ft, Ro err a frew-regt a ap R maa ee2Y So A 3. Further, | shall also be liable for any civil or eriminal action in accordance with law, in case of any falsehood or misrepresentation, ‘Suuerai I euaTeT/Signature of Depositor: atta/Date: 13-10-2023 weriPlece:. yi Kala..Aharmef ‘ari #1 7TH/Name of Depositor: Prabhavati Devi shares! 74 Mobile No: Tore 82922 g 9273939DDSocanacccren,