Annexure- A

LETTER OF DISCLAIMER
(To be stamped as per the Stamp Act applicable to the State)

The Branch Manager

_________________

----------------------------

Dear Sir,

___________________________________*Account No _______________________in the

name of
Shri/Smt./Kum._________________________________________________________
Balance ____________________________________________________________

With reference to the above account, I/We, the following legal heirs of the late
Shri/Smt./Kum._____________________________________________________________
___
(Name of the deceased account holder), have to advise that we have no interest in the
above assets and as such we have no objection to your paying the balance amount lying in
the above account(s) with you in the name of the aforesaid Shri/Smt./Kum
__________________________
____________________________(Name of the deceased account holder) to
Shri/Smt./Kum.

1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
4.____________________________________________________________________
5.____________________________________________________________________

Such delivery of the payment of the balance in the above account(s) would be completely
binding on us and we will not question the Bank’s action in so doing if any proceedings.
I/We undertake to bind ourselves, our heirs and legal representatives not to revoke the
declaration made herein.

Name(s) of the Claimants

Sr. No (who relinquish their rights) Age(yrs) Signature

Signed before me this ______day of _______________20____

Notary
Public/Magistrate)
*fill in here the type of account viz. SB/R.D/Term Deposit, Current etc.

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 Annexure B
AFFIDAVIT
(To be stamped as per the Stamp Act applicable to the State)

I/We_____________________________________S/D/O______________________
residing at _________________________________________________ and
_______________________
__________________________S/D/O_______________________________________resi
ding at ___________________________________________________________do hereby
make oath*/solemnly affirm and say as follows:
That Shri/Smt./Kum. _________________________________ (Name of the deceased)
hereinafter, referred to as “the deceased” died intestate on ____________at
_______________

2. That we know the deceased and his/her family since the last_ _________ years.

3. That at the time of his death the deceased left surviving him/her the following persons
who according to the law by which they are governed, are the only legal heirs of the
deceased entitled
to succeed to the estate of the deceased on an intestate succession:

SNO. Name Age(yrs.) Relationship with the deceased

4. That I am not related in any manner whatsoever to the deceased or any of the above-
mentioned persons nor have we any claim or interest of whatsoever nature in the estate of
the deceased.

5. That we are informed, and we verily believe that the deceased has left certain deposits*/
assets with the ________________Bank ________________________________branch, to
which the above-mentioned persons are entitled to claim.

6. That we are making this solemn declaration sincerely and conscientiously believing the
same to be true and with full knowledge that it is on the strength of this declaration that the
_____________________Bank _____________________________branch, has agreed at
our request to make payment of the amount of the deposits/ to deliver the assets to the
above mentioned persons without insisting on production by them of a grant of legal
representation to the estate of the deceased from a competent Court.
Sworn*/ solemnly affirmed at this ________
day of _________________ 1. ___________________________

2.___________________________

in the presence of ___________________ before me

*(Delete whichever is inapplicable) Judge / Magistrate / Notary

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 Annexure C

LETTER OF INDEMNITY
(To be duly stamped as per the Stamp Act applicable to the State)
(Letter of Indemnity with respect to payment of Balance in the Deceased Constituents
Account without production of Legal representation)
To,
The Branch Manager
_______________
__________________

IN CONSIDERATION of your paying or agreeing to pay us,

Insert here the names
of the claimants
1 ___________________________________________
2. ___________________________________________
3. ___________________________________________
4. ___________________________________________
5. ___________________________________________

The sum of Rupees__________________________________________standing at the

credit of Saving Bank / Current / R.D Account No. etc. with your Bank in the name of
Shri/Smt./Kum. __________________________________since deceased, without
production of Letter of Administration or a Succession Certificate to his/her estate, we

Insert here the

Names of the
suret(y/ies
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 assign against all claims, demands, proceedings, losses, damages, charges and
expenses which may be raised against or incurred by you by reasons or in consequence
of your having agreed to pay / or paying me / us the said sum as aforesaid.

Signed, Sealed and delivered by the above named on this ________day of

__________two thousand__________________.

SIGNED AND DELIVERED by the above named

1._____________________2. ____________________3. ______________________

4._____________________5. ____________________
(Heirs/claimants of the deceased)
SIGNED AND DELIVERED by the above named

1._________________________________ 2. _______________________________
(Sureties)

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 Annexure D
Opinion Report on Surety

1. Name in Full
2. Address

3. Academic Qualification
4. Age
5. Occupation

(If employed, please state the

name of the employer and since
when Employed).
6. Present Monthly Income / Salary
(Attach a Salary Certificate, if
income is by way of salary)
7. Total yearly income from all sources
8 No. of dependents
9 Personal Assets
a. Immoveable Property viz. land /
Building / flat etc. give details
acquisitions, present value etc.
b. Investments (Fixed Deposits,
Shares etc. if any)
c. Life Insurance Policy
d. Other Assets
e. Details of Bank Accounts, if any
(Name and address of Bankers
with Account No (Current /
Savings) to be furnished).
10 Personal Liability if any
11 Please indicate whether surety is related to claimants Yes/No
12 Period for which claimants are known Yrs.
I confirm that all the statements made by me in this application are true and correct and
have been made by me.

Place:

Date: Signature
(Surety)
Remarks of the Divisional Manager/ Branch Manager
Divisional Manager/ Branch Manager

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 Annexure – E

Form of Inventory of Contents of Safe Deposit Locker

(To be used where there is no nomination or survivorship clause)

The following inventory of contents of Safe Deposit Locker No. ___________ located at
_____________________________ Branch of ___________________________ Bank.
* hired by Shri/Smt. _________________________________ (deceased) in his/her sole
name.
*hired by Shri/Smt. (i) ___________________________________ (deceased)
(ii) ___________________________________ jointly
(iii)____________________________________
was taken on this ______________ day of _________________ 20______.

SNO. Description of Articles in Safe Deposit Lockers Other identifying particulars

if any

For the purpose of inventory, access to the locker was given to the legal heir(s)/a person
mandated by the legal heir(s) and surviving hirers

• By breaking open the locker under his/her/their instructions.

• Who produced the key to the locker (Delete whichever is not applicable)

The above inventory was taken in the presence of:

Legal heirs of deceased joint hirer(s)/person mandated by legal heirs

1. Shri/Smt.______________________________ __________________
Address ______________________________ (Signature)

Shri/Smt.______________________________ ___________________
Address ______________________________ (Signature)
And
Shri/Smt. ________________________ ___________________
Survivors of Joint hirers (Signature)
Address _____________________________________

Shri/Smt. ________________________ ___________________

Address _________________________ (Signature)

2. Witness (es) with name, address and signature:

Shri/Smt.______________________________ ___________________
Address ______________________________ (Signature)

Shri/Smt.______________________________ ___________________
Address ______________________________ (Signature)

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 ACKNOWLEDGEMENT

* I, Shri/Smt. ___________________________________________legal heir/mandate

holder

* We, Shri/Smt. _______________________________________________

_______________________________________________
_______________________________________________ legal heirs and

Shri/Sm _______________________________________________
_______________________________________________
_______________________________________________ surviving hirers

Hereby acknowledge the receipt of the contents of the safe Deposit locker comprised in as
set out in the above inventory together with a copy of the said inventory.

Shri/Smt. ____________________________
(Legal Heir/Mandate Holder)

Shri/Smt. ________________________ Signature __________________

Shri/Smt._________________________Signature __________________
Shri/Smt. ._______________________ Signature ___________________

Date & Place ________________________

(* Delete whichever is not applicable)

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 Annexure – F
Form of Inventory of articles left in Safe Custody
(To be used where there is no nomination or survivorship clause)

The following inventory of articles left in safe custody with

_______________________branch of _______________ Bank by Shri/Smt.
__________________ (deceased) under an agreement/receipt dated _____ was taken on
this, ______ day of _____20 ____.

SNO. Description of Articles in Safe Custody Other identifying particulars, if

any

The above inventory was taken in the presence of,

Legal heirs or a person mandated by legal heirs

1. Shri/Smt.______________________________ __________________
Address ______________________________ (Signature)

2. Shri/Smt.______________________________ __________________
Address ______________________________ (Signature)
________________________________________________________________________
ACKNOWLEDGEMENT
* I, Shri/Smt. __________________________________________ legal heir/mandate holder

* We, Shri/Smt ________________________________________________

________________________________________________
________________________________________________Legal heirs
and
Shri/Smt. _______________________________________________
_______________________________________________
________________________________________________ Surviving
hirers
Hereby, acknowledge the receipt of the contents of the safe Deposit locker comprised in as
set out in the above inventory together with a copy of the said inventory.

Shri/Smt. ____________________________
(Legal Heir/Mandate Holder)

Shri/Smt. ________________________ Signature __________________

Shri/Smt._________________________Signature __________________
Shri/Smt. ._______________________ Signature ___________________
Date & Place ________________________
(* Delete whichever is not applicable)

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 Annexure – G
LETTER OF INDEMNITY WITH RESPECT TO DELIVERY OF ARTICLES KEPT IN BANK’S SAFE DEPOSIT
VAULT / SEALED BOXES ETC. OF THE DECEASED WITHOUT PRODUCTION OF LEGAL
REPRESENTATION
(To be stamped as an agreement)
To,
________________________
________________________

In consideration of your delivering or agreeing to deliver to me/us

_______________________________
_______________________________
(Insert here the names of the heir(s) of the deceased)
The articles/properties mentioned hereunder -
Safe Deposit Details of the Weight Value
Locker
No./Sealed articles/proper Description
Box in Safe
Deposit
Account No.

and held in the name(s) of ___________________________ since deceased, without

production of any succession certificate/ letters of administration to his / her / their estate or
a certificate from the Controller of Estate Duty to the effect that the estate duty has been
paid or will be paid or none is due,

I/We ______________________and ____________________and _________________

(State here the names of the heir(s) of the deceased).
and we ____________________________and________________________________
(State here the name of the sureties)
do hereby for ourselves and our heirs, legal representatives, executors and administrators,
jointly and severally undertake and agree to indemnify you, the Bank, and its successors
and assigns against all claims, demands, proceedings, losses, damages, charges and
expenses which may be raised against you or incurred by you by reason or in consequence
of having delivered or agreed to have deliver to me/us the above mentioned
articles/property of the deceased from the safe deposit locker/sealed boxes in safe deposit.
Signed sealed and delivered by the above named on this ______ day of ________ Two
thousand and ______.

SIGNED AND DELIVERED by the above named

(1)____________________________________
(2)____________________________________
(Heirs of the deceased)

SIGNED AND DELIVERED by the above named

(1) ____________________________________
(2)____________________________________
(Sureties)
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 RECEIPT

Received from _____________________ Bank _______________________ Branch

Rs._______ (Rupees ____________________________________ only) by Banker’s
Cheque No. _____________________ dated ________________ in favour of
_____________________________________________being the balance standing at the
credit of Saving Bank Account/ Current Account/ TDR/ STDR No. _________________ in
the name of ____________________________________. The balance has been paid to
me as per Bank rules.

Date : Signature of Claimant

Place: Name:

Declaration in case funds are settled in favour of Minor

I, ____________________________________________, father/mother and natural

guardian of
______________________________________________ hereby certify that the proceeds
of your Banker’s cheque No. _____________ dated _______________ favouring
___________________________ issued by you in full and final settlement of the balance
in Account No. _________________ of Late ____________________________________
will be utilized for the benefit of the minor only.

Place:
Date: ___________________
(Signature of Guardian)

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 FASCIA SIGN WITHOUT BRANCH NAME

BANK OF BARODA
Annexure H
LETTER OF INDEMNITY
In respect of payment of balance in deposit accounts of Missing person presumed to
be dead (To be stamped as an agreement)

The Branch Manager Place : ____________

Bank of Baroda Date : ____________
__________________

WHEREAS Mr/Mrs/Miss _______________ ( name of the Missing person

presumed to be dead) of _________________ (address of the Missing person
presumed to be dead) had at the time of his/ her missing to his/her credit a
sum of Rupees _______________ (balance in the account as on the date of
missing) which including interest upto __________ (date of repayment)
amounts to ` __________ (amount now being repaid) in__________ (nature of
account) account/s with the Bank of Baroda,
_____________ Branch, (hereinafter referred to as "the said Bank").

AND WHEREAS ____________________ (names of the persons claiming

repayment)
_____________________ of _______ (address) _________________
(hereinafter referred to as "the said claimant/s") and _____________ have
represented to the said Bank that the said claimant/s is/are entitled to have
the said sum paid to the said claimant/s and have accordingly requested the said
Bank to pay the said sum to the said claimant/s.

AND WHEREAS the said claimant/s and Mr/Mrs/Miss __________ (names of

the
surety/ies) ________________ of _____________ (address of surety/ies)
___________ have agreed to indemnify the said Bank in respect of such
payment.
NOW IN CONSIDERATION of the premises we, __________ (name/s of
claimant/s) __________________ And _________________ (name/s of
surety/ies) _________
for ourselves and our respective heirs, executors and administrators jointly and
severally agree and undertake that the said Bank, its successors and assigns and
its Managers, Agents, Officers and Servants, and their respective estates and
effects are and shall from time to time and at all times hereafter be kept safe
and saved harmless and indemnified for and in respect of such payment and
against all actions, losses, costs, charges, expenses and demands whatsoever in
respect of the said payment.
Yours faithfully,
________________________
_______________________(To be signed by the claimant/s and surety/ies)
\\headofintops746\e drive\bina19\circular\website- settlement of claim in respect of deceased constituients.docx

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