Details in Separate Sheet

1-Name & address of the Depositor-

2-No.&Type of Account (SB/RD/TD)
3-Office at which A/C standing (I) B.O.
(II) S.O.
(III) H.O.

4-Balance Shown in the Passbook

(Pass book or attested photo copy to be
attached)
5-Balance shown in H.O.ledger Card
(attested photo copy of H.O.ledger card to
be attached)
6-Amount of Fraud involved for restoration
( Statement or attested photo copy of
statement of main offender and depositor to
be attached)

Deposit (including Default) Withdrawal Remark

1
2
3
4
5
6
7
8
9
10
dqy
dqy nkok :

Seal and Signature of Sub Divisional Head

 Details in Separate Sheet
1-Name & address of the Depositor-

2-No.&Type of Account (SB/RD/TD/SSA)

3-Office at which A/C standing (I) B.O.

(II) S.O.

(III) H.O. Raipur GPO

4-Balance Shown in the Passbook As per Passbook Bal Shown Rs.

(Pass book or attested photo copy to be Photo copy of Pass Book attached
attached)
5-Balance shown in H.O.ledger Card As per ledger Bal Shown Rs
(attested photo copy of H.O.ledger card to Photo copy of ledger attached
be attached)
6-Amount of Fraud involved for restoration Rs
( Statement or attested photo copy of Photo copy of Statement of
statement of main offender and depositor to
be attached)

Deposit (including Default) Withdrawal Remark

Sl Date Amount Sl Date Amount
No No

Total Total

Net Claim =
 Seal and Signature of Sub Divisional Head

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izfr]
eq[; iksLVekLVj tujy
N-x-ifjeaMy jk;iqj 492001

dzekad%& ,Q 4@Mh 2@2017 jk;iqj fnukad 22-05-2019

fo"k; %& Jh ghjkjke jksfgnkl 'kk[kk Mkdiky eqM+ikj¼oVxu½ }kjk fd;s xcu izdj.k
esa cpr [kkrk dzekad
854236 ds nkok izdj.k dh Lohd`fr ckcrA

lanHkZ% ifjeaMy dk;kZy; jk;iqj dsl ekdZ vUos@fofo/k&60@jk;iqj@2018

 d`Ik;k mijksDr fo"k;karxZr ys[k gS fd 'kk[kk Mkd?kj eqM+ikj¼oVxu½ cpr [kkrk
dzekad 854236 Joint B tekdrkZ Jh fj[khjke lkgw ,oa Jh jke flag lkgw xzke iks0 eqMikj
laMh Ogk;k oVxu ds uke ij [kksyk x;k gS A iklcqd ds vuqlkj mDr [kkrs dk cSysal
34950@& : gSA iz/kku Mkd?kj jk;iqj ds ystj ds vuqlkj cSysal : 100@& ,oa C;kt :
26@& gSA Jh ghjkjke jksfgnkl }kjk mDr [kkrs ls fofHkUu fnukadks dks dqy :
34850@& dh izo`f"V iklcqd esa fd;k x;k gSA ysfdu bls Mkd?kj ds fglkc esa ugha fy;k
x;k gSA [kkrk /kkjd }kjk vius c;ku esa ;g Lohdkj fd;k x;k gS fd muds }kjk tek gsrq jde
o iklcqd Jh ghjkjke jksfgnkl dks fn;k x;k FkkA Jh ghjkjke jksfgnkl }kjk jde iklcqd esa
ntZ fd;k x;k gS ysfdu Mkd?kj ds fglkc esa ugha fy;k x;k gSA bl izdkj Jh ghjkjke
jksfgnkl }kjk bl [kkrs ls dqy ’kkldh; jde : 34850@& dk nqfoZfu;kstu fd;k x;k gSA

Jh jke flag lkgw dk nkok QkeZ : 34850@&,oa psd fyLV fuEukafdr nLrkostksa dh
Nk;k izfr ds lkFk layXu dj Hksth tk jgh gS A d`i;k nkok Lohd`r djus dh d`ik djsaxsA
layXu
1-psd fyLV
2-nkok QkeZ ¼ewy½
3- Jh jke flag lkgw dk c;ku dh lR;kfir izfr
4- iz/kku Mkd?kj jk;iqj dk ystj dh lR;kfir Nk;k izfr
6- iklcqd dh lR;kfir Nk;k izfr
izoj v/kh{kd Mkd?kj
jk;iqj laHkkx jk;iqj

22-05- egksn;
2019
1- Jh ghjk jke jksfgnkl xzkeh.k Mkd lsod 'kk[kk Mkdiky
¼iqV vkQ½ eqM+ikj ¼oVxu½ }kjk fd;s x;s
 nqfoZfu;kstu ds laca/k esa milaHkkxh; fujh{kd Mkd?kj
cykSnkcktkj milaHkkx cykSnkcktkj }kjk eqMikj cpr
[kkrk dza 854236 ds nkok izdj.k : 34850@& ds Lohd`fr
ds laca/k esa izsf"kr jiV] nLrkost ,oa tekdrkZ Jh jke flag
lkgw xzke iks0 eqMikj Ogk;k oVxu dk c;ku layXu gSA
2- mDr Jh ghjk jke jksfgnkl }kjk fofHkUu fnukadks dks
dqy : 34850@& dh izo`f"V iklcqd esa fd;k x;k gSA
ysfdu Mkd?kj ds fglkc esa ugha fy;k x;k gSA bl izdkj Jh
ghjkjke jksfgnkl }kjk dqy ’kkldh; jde : 34850@& dk
nqfoZfu;kstu fd;k x;k gSA milaHkkxh; fujh{kd Mkd?kj
cykSnkcktkj milaHkkx cykSnkcktkj ds jiV fnukad 29-
10-2018 ds vuqlkj Jh ghjk jke jksfgnkl }kjk nks [kkrksa
ds vykok fdlh vU; [kkrk ds laca/k esa c;ku ugha fn;k tk
jgk gSA ftlds dkj.k mudk c;ku izkIr ugha fd;k tk ldk gSA
vr% ;fn lger gks rks mDr nLrkost vk/kkj ij gh Jh ghjk jke
jksfgnkl xzkeh.k Mkd lsod 'kk[kk Mkdiky ¼iqV vkQ½
eqM+ikj ¼oVxu½ }kjk fd;s x;s nqfoZfu;kstu dh jde esa
mDr jde dks tksMrs gq, ] dqy : 34850@&dk Restoration
dh Lohd`fr vkns’k tkjh djus ckor nLrkostksa ds lkFk
ifjeaMy dk;kZy; dks Hkstus ckor vkns'kkFkZ izLrqr
gSA irz o psd fyLV dk izk:i vuqeksnukFkZ izLrqr gSA