FORM - F

(See sub-rules (3) and (4) of rule 8)

Serial No…………………..
APPLICATION FOR CLOSURE OF ACCOUNT UNDER SENIOR CITIZENS SAVINGS SCHEME, 2004
BY SPOUSE(JOINT HOLDER) / NOMINEE(S)/LEGAL HEIRS
TO
The Postmaster/Incharge,
……………………………………………………(name of the Deposit office)
…………………………………………………….

Subject: Application for withdrawal /closure of account.

Sir,
I/WE* …………………………………………………………………… the spouse (Joint holder) / nominee(s) /legal heirs of
late……………………………………………. , the depositor to the Senior Citizens Savings Scheme, 2004 account
No…………………………………………….. wish to withdraw the entire amount standing to the credit of the deceased in the
said account.

Please find enclosed: -

(i) A certificate in regard to the death of the Depositor.
(ii)*A Certificate in regard to the death of Shri/ Shrimati…………………………………………………………………….and
Shri/Shrimati………………………………..……………………… also the nominee(s) appointed by the Depositor.
(iii)* * Succession Certificate/Letter of Administration with attested copy of probated will of the deceased
depositor issued under the provisions of the Indian Succession Act, 1925.
(iv) Pass Book of the Depositor.
(v) # Letter of Indemnity.
(vi) # Affidavit.
(vii) # Letter of disclaimer on affidavit

Signature or thumb impression of claimant(s)

Witness……………………………………………
…………(Signature, name and address)………..

Date ………………………………………………………………..

Place………………………………………………………… …….

FOR USE BY THE DEPOSIT OFFICE

Withdrawal of ` …………………………………… (Rupees………………………………………………………………………….…….) is

sanctioned.

Adjustments made (to be specified) ` ………………… ……………………….

(Rupees…………………………………………………..)

NET AMOUNT PAYABLE ` ……… ………..… … …… … …

(Rupees……………………………………...…………………………………)
 RECEIPT TO BE SIGNED BY THE CLAIMANT(S)

Received a sum of ` ……………………………………. (Rupees………………………………………………………………………….)

from………………………………………………………….. (Name of Deposit office) as per details furnished above, in full
settlement of our claim.

Signature / Thumb impression of the claimant(s)

Signature of in-charge of Deposit Office

(Alongwith name and designation stamp)

*: Delete whichever is not applicable.

**: Strike off if there is a valid nomination.
#: To be produced by legal heirs, in the absence of nomination(s) for claims upto ` 1 lakh.
 ANNEXURE-I TO FORM - F
(Letter of indemnity)

TO

The Postmaster / Incharge,

……………………………………… (Name of the deposit office)

In consideration of your payment or agreeing to pay me/us …………………………………………………………………………

………………..
[Name(s) of Legal heir(s)] the sum of ` ………………………… (Rupees……………………………………………………
……………………………………………………..) standing in the account No…………………………………………under SENIOR
CITIZENS SAVINGS SCHEME, 2004 with your office in the name of ……………………………………………………… .
…………… ……………… …………without production of letters of administration or a succession certificate to the
estate of the deceased……………………………………………………………………(name of the depositor),
I/We……………………………………………………………………………………………………………………… and
we…………………………………… ……………………………………………….. (sureties) do hereby for ourselves and our heirs,
legal representatives, executors and administrators jointly and severally undertake and agree to indemnify you and
your successors and assigns against all claims, demands, proceedings, losses, damages, charges and expenses
which may be raised against or incurred by you by reason or in consequence of having agreed to pay/or paying
me/us the sum as aforesaid.

In witness whereof we have hereunto set my/our hands at this……………..day of………………………………in the
presence of witnesses,

Signed and delivered by the above named

heir/heirs of the deceased.

Signed and delivered by the

above named sureties (Signature, names and address)

1.

2.

Signature, names and address of witnesses:

1.

2.
ATTESTED

NOTARY PUBLIC
 ANNEXURE-II TO FORM - F
(Affidavit)

TO

The Postmaster / Incharge,

………………………………………(Name of the deposit office)

I / We……………………………………………….Husband of / wife of late……………………………………..………………………………

aged………….. aged………….. aged………….. sons/daughters of the said late……………………………………………………………………
resident of………………………………………………………………………….do hereby declare and solemnly affirm as under :-

(1) That I / we am/are the only heir(s) of the deceased………………………………………….who died at……………………………..
on……………………………………. I / We alone represent the estate of Shri/Smt……………………………………………………

(2) That the deceased…………………………………..did not leave any will and therefore I / we are the only successor(s) to
the estate of the said deceased.

1.

2.

3.

DEPONENTS

VERIFICATION: I / We, the above -named deponents do hereby verify on solemn affirmation in…………………………………
(name of place) that the contents of this affidavit are true to the best of my/our knowledge and nothing material has been
concealed.

Dated………………….

1.

2.

3.

DEPONENTS
ATTESTED

OATH COMMISSIONER or NOTARY PUBLIC

 ANNEXURE-III TO FORM - F
(Letter of disclaimer on Affidavit)

TO

The Postmaster / Incharge,

………………………………………(Name of the deposit office)

I / We (i) …………………………………………….Husband of / wife of …………………………………………..…………………………….

Resident of…………………..……………………………………………………………………………………………………………………………………………
(ii) ……………………………………………………….………… son/daughter of ………………………………………….………………………………
(iii) …………………………… ………………………………………son/daughter of ……………………………………….……………………………………

do hereby declare and solemnly affirm as follows :-

(1) That Shri/Smt………………………………………………………………………………….died intestate on…………………………….……

leaving behind us……………………………………………………………………………………………..his/her only heirs.

(2) That we…………………………………………………………………………………………………..heirs of our late father/mother for

ourselves and on behalf of our heirs, executors, representatives and assigns to hereby relinquish our claims to the
balance
of ` ………………………………………………………which may be credited to the account sought by our mother/father to
be
opened in the deposit office in the name of the estate of the said………………………………………………………………………………...
deceased father/mother after the realisation of Draft No…………………………………………………on
………………………………….
issued by …………………………………………………………………………………………………….. (name of the deposit office) and we
have no objection whatsoever in the balance in the above -referred account No………………………………………together
with
interest, if any, accrued thereon being paid by the Deposit office to our mother/father
Mrs./Mr……………………………………………………………

1.

2.

3.

DEPONENTS
VERIFICATION: I / We, the above -named deponents do hereby verify on solemn affirmation that the contents of this
affidavit are true to the best of my/our knowledge and nothing material has been concealed.

Dated………………….
1.

2.

3.
DEPONENTS

I identify the deponent(s) who is/are personally known to me and

who has/have signed in my presence.

Dated…………………………
OATH COMMISSIONER or NOTARY PUBLIC