@ar ster TTA ara siqilu 4i@/Claim Request Date :_05 Apr, 2024 fou selcapeicur,/ Dear Sir/Madam, #, (RI 7H/L, Full Name : Meera Devi fay/afa #1 4F/Father/Husband Name : W/O: Shiv Kumar ai/Address 1: 246 ka, Naramau Bangar ak ‘Mandhana wt wa/Address = _ > el oe ERT ae / faiei/District : “Kanpur Nagar Sign across the photo fi @is/Pincode : 209217 ‘uvy/State : Uttar Pradesh ory Slant: 1980, a> ant AR Peiferiad da 4 oe 61 ar eared 2 ren RUFT) siRTETT MAA) & FRIED era fey awe we :- Date of Birth : 1980, do hereby apply for a claim against my deposit(s)/ contribution(s) amount which is to be credited to my following Bank :- ‘i m1 7F/Bank Name: BARODA UTTAR PRADESH GRAMIN BANK Bh op at 7 rear aaa &: Following are my deposit details: or or et | eos] centr jes] “se | er | eS, fee cacioey | ome) Te A “Membership | Account| [Account| Deposit) eicin| sate} scnme| Members rcent| ge | cacy [AIRY Dera | pepe No | Gods | Name cnn sna esatn ra Pr es 20-09. 1 [onse| re foezzo0ay Jrcsnasserelrasoosassoes] 202% | aoa 2 [mse] Se farznomen| — [aconaanelrosossion| 2 | ano 2 unse] Ze forenoon] — [aconssrnfrasocason] Seat | amas + [suse] Fv fownzcooens) — fruorasser rsoasassaea] 200% | aceraisu / Declaration ‘aera are Pear ara 14 Meera Devi Weer! Stsor axa g f% 4 Saharayn Universal Multipurpose Society Limited # w& aries orripece & ate 4 ge omer He A ae Ree Ree sige ee aA A te eT Re #1 AA oR effet at eae ahoraait 4 AY ere ser GY ag enh erefDat ar Rlawor ars 1 safer wer quar AT arian sie fazer Hoga oh a 8 ate A) ot aor ate cd at we wee Rar 8 1 ver aaRVerraai Rant Saharayn Universal Multipurpose Society Limited 4 48 44 aia 8 dent de walinea ekisd fe. raw; HER apenta seins dhiget fe, sivet sik cant sar dite alsinnfes dred fe. Been SH cen ¥ Raia 22.03.2022 @ vedi sk deni veidivis olsinfea dhagd fet, dcuare A aut 4 Rim 29.03.2023 & vec site idler sears art SEgeTERT A rar Tare 1 1. Meera Devi hereby declare that I am a genuine depositor/member of Saharayn Universal Multipurpose Society Limited and have made legitimate deposits in this Society as per the details given above in this application 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 Saharayn Universal Multipurpose Society Limited out of my legitimate income before 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, a 2 are orem onder wee Hg ag A Qe are Aer an Mar ner Sh, At A ary aera aA ae ds Fi wit werashaneies ths wren’ 4 are oer oie Tens Qs are’ F sea UA A sfagd at A saan aan @ 14 were shaneaigs Qibs aren’ are Praerst af ara ear cep yard ah Bett sea ada Sah worsaTst 1 2. If any of the information given by me in the above application form is subsequently proven to be incorrect or false, I 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. I shall also not pursue the claim in other forum to the extent it is settled by the 'Sahara-CRCS Refund Account’. 3. ee ote, Reef arc at Pega sgh $Y aan H ai seg Roh FOr ar omen ge dH oe seer3. Further, I shall also be liable for any civil or criminal action in accordance with law, in case of any falsehood or misrepresentation. fa/Date: 05 Apr. 2024 srirpaf a exTER/Signature of Depositor: afte ex ‘waraaf a1 a14/Name of Depositor: Meera Devi GE larger 4ax/ Mobile No: 9453816469