FORM OF RECEIPT AND DISCHARGE FOR THE SURRENDER PROCEEDS

Policy No : 50170207
Policy Owner / Assignee : MR M N JEEWAKA STEMBO (Deceased)
Beneficiary : MRS E L PEIRIS
Surrender Value : Rs. 958,557.91

I/We the above Policy Owner/Assignee/Beneficiary do hereby acknowledge receipt from AIA Insurance
Lanka Limited the above sum of money as per details shown below being the surrender value of the above
mentioned policy, which is herewith delivered up to the said company to be cancelled. In witness where of
these presents are subscribed by me/us
at ......................................................................... on the .............................................................day
of ..................................................... 20 ..............

Surrender Value Rs. 958,557.91

Less
Policy Loan ……..………………
Interest thereon ……..………………
Net Amount Payable Rs. 958,557.91

WITNESSES
Name :.................................................. Occupation :.......................................................
Signature :................................................... Address :.........................................................

The values indicated will change subject to the conditions at the time of payment due to unit price
fluctuations, payment of subsequent premiums or accumulation of interest of any loans obtained,
after the date on which this discharge is printed.
If you do not have an account, open with a bank convenient to you and give us the details. The
payment will be credited directly to your bank account mentioned in the discharge receipt. Please
inform us if it is not credited within 7 working days.

Details of Policy Owner/Beneficiary

Name :....................................................................................................
Permanent address :....................................................................................................
Citizenship - Sri Lankan U.S. Other (Specify) :.................................................................
Residential Status - Residing in Sri Lanka Not residing in Sri Lanka
If not specify county of residence :......................................................................................
Please provide details if you are dual citizen :..........................................................................
U.S. Citizen or resident please give U.S. taxpayer I.D No. :.......................................................
Continued.…

[AIA – INTERNAL]
 Declaration
I,.................................................................................................................................................................

(Full name of Policy Owner/Beneficiary)

aged………………….years, residing at…………………………………………………………………

hereby declare that the answers to the above questions are complete and true in each and every respect.

I am claiming the policy monies as ……………………………………………………………………..

(Relationship/interest)

I/We fully understand that AIA Insurance Lanka Limited (the company) and its affiliate (“the group”) are
subjected to and required to, or has agreed to, comply with certain legal, regulatory and/or other
requirements (the “Reporting Requirements”). As such, I/We provide our express consent that the
Company shall have the right to provide any information to any governmental authorities, regulatory bodies
and/or any other person(s) in respect of the Reporting Requirements. I/We understand that such disclosures
may involve the cross border transfer of personal data outside the Sri Lankan jurisdiction and that such
disclosures may be respect to i) the personal data of the Policy Owner, the Life Assured, and the
Beneficiaries (“the parties”), or any of the; ii) any information relating to the Policy related to this Claim;
and iii) any information relating to any other policies held by the Parties or any of them.
By signing below, “I/We hereby declare, agree and represent that I am /we are not a “U.S. Person(s) federal
income tax purposes and that I am/we are not acting for or on behalf of a U.S. Person.

Dated at …………………………this…………………………..……day of…………....…20………...

Stamp of
................................................................ ……….................................................
Rs. 50
National ID card No of the Beneficiary Signature of Beneficiary

Tel No: ...................................

Payment Instructions

Bank :............................................ Account No :................................................................

Branch :............................................ Name of A/C holder :..........................................................

If you do not have an account at the moment, please do open with any bank convenient for you & give us the details.
The payment will be credited directly to your bank account mentioned by you in the discharge receipt. Please inform
us of same in the event if it is not credited to said bank account within 7 working days

[AIA – INTERNAL]