Exim Bank Claim Form

Exim Bank
TD- claims-1
Application for Deceased claim (To be used when account has nomination clause)
Place:
Date:
The General Manager
Export-Import Bank of India
21st Floor, World Trade Centre,
Cuffe Parade, Mumbai-400005
Dear Sir,
Re: FD account of Deceased Late MR/Ms...
Account No(s)..
I/We advise the demise of Mr/Ms. _______________________ on __________________. He/She holds the
above FD account(s) in your Bank. The account/s is/are in the name(s) of:
i)
____________________________________
ii)
____________________________________
iii)
___________________________________
I,son/daughter of Mr....
residing at .am
(i)
(ii)
the registered nominee in the above account(s).

the person authorized to receive payment on behalf of Master / Miss
.. who is the nominee in the above account(s) and is a minor as on the
date of this claim.
Please settle the balance in the account in the name of the nominee. I/we receive the payment as trustee(s) of
the legal heirs of the deceased.
I/We submit photocopy of the following document(s) together with originals. Please return the original to us
after verification.
i)Death Certificate issued by.
ii) Identity proof . (enclose Election ID Card/ PAN Card / Passport)
iii)Address Proof.(attach ration card/electricity/telephone bill/municipal tax receipt)
iv) Photograph and signature of the claimant on the Annexure (duly attested by the Branch Manager of the
Bank where the claimant is maintaining the account along with details of account.)
Yours faithfully
(Claimant(s)
Name
Signature
Address :..
Telephone/Mobile No.:..
Exim Bank
TD- claims-2
Application for Deceased claim (To be used when account is a joint account with survivor clause)
Place:
Date:
The General Manager
Dear Sir,
Re: FD account of Deceased Late MR/Ms...
Account No(s)..
I/We advise the demise of Mr/Ms.on...
He/She holds the above FD account(s) in your Bank. The account/s is/are in the name(s) of:
i)
ii)
iii)
I/We Request you to delete the name of deceased person and continue the account in my /our name(s) with
same mode of operations.
I/We submit photocopy of the following document(s) together with originals. Please return the original to us
after verification.
i)Death Certificate issued by.
ii) Identity proof (if not already submitted). (enclose Election ID Card/
PAN Card / Passport)
iii) Address Proof(if not already submitted)(attach ration card/electricity/telephone
bill/municipal tax receipt)
iv) Photograph (if not already submitted) and signature of the claimant on the Annexure (duly attested by the
Branch Manager of the Bank where the claimant is maintaining the account along with details of account.)
Yours faithfully
(Claimant(s)
Name (s)
Signature(s)
1.
2.
Address :..
Telephone/Mobile No.:..
Exim Bank
Annexure-1
VERIFICATION OF SIGNATURE AND PHOTOGRAPH OF THE ACCOUNT HOLDER
This is to certify that Mr /Ms..Son/Daughter of

Mr
Residing at
..
is maintaining a Savings Bank/Current account No.
with our branch. The signature and photograph of the above account holder is attested here under:
Signature of above Account holder
Photograph of above Account holder

signed across by the Branch Manager
Signature of the Branch Manager:

Name of the Branch Manager:
Name of the Bank:
Name of Branch :.
Complete address:..
Telephone No:
Branch Seal
Exim Bank
TD- claims-3
Application for Deceased claim

(To be used for cases other than Nomination / joint account with survivor clause)
The General Manager

Dear Sir,
Re: FD Account of the Deceased Late Mr/Ms..
Account No(s)..
I/We advise the demise of Mr/Ms on ..
He/She holds the above account(s) at your branch. The account(s) is/are in the name of:
1
2
3
I/We lodge my/our claim for the balances with accrued interest lying to the credit of the above named
deceased who died intestate. I / we am / are the legal heirs of the above named deceased and lodge
my/our claim for payment as per the banks rules and discretion. The relevant information about the
deceased and the legal heirs are as under.
1. Names in full of the parents of the deceased:
Father: ..
Mother:
2. Religion of the deceased:..
3. Details of living (i) Husband (ii) Wife (iii) Children (iv) Father (v) Mother (vi) Brothers (vii) Sisters
(viii) Grand Children. If Hindu Joint Family, the name and address of the Karta and Co-parceners
with their respective ages.
Full Name/Address
Occupation
Relationship with Deceased
Age
1
2..
3..
4.......................
5.
6.
5. Name or Names of the Guardian/s of
the minor Children of the Depositor
(a) Whether Natural Guardian :.

(b) Whether Guardian appointed by a Court of Law in India:..
(If so, attach a certified copy or duly attested copy of such Order)
(c) In whose custody the Minor/Minors is / are?:
6. Claimant/s name/s and address in full:
(i)
(ii)
(iii)
(iv)
I/We submit the following documents.

verification:
Please return the original death certificate to us after
1. Death Certificate (Original + 1 photocopy) issued by: ..

2. Succession certificate/ Letter of Indemnity ( on the format provided by the Bank for claims up
to Rs 50000)
We request you to pay the balance amount lying to the credit of the above named deceased to
Mr/Ms on my/our behalf.
(name of the person in whose name settlement cheque is to be issued)
The details of the Bank account of the said Mr/Ms are as under:
Account type (Savings Bank/Current):
Account No:
Name of the Bank:
Name of the Branch(with address and Telephone No.):.................
.
MICR code IFSC Code:..
I/We hereby solemnly affirm that the above statements are true and correct to the best of my/our
knowledge and belief.
Yours faithfully,
Name of Claimant(s)
Address
Signature (s)
1..
2..
3..
4..
Date:
Place:
Exim Bank
Annexure 2
Indemnity format
(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
The General Manager
IN CONSIDERATION of your paying or agreeing to pay me/us,

Insert here the
Name(s)
Claimants
1)
2)
3) ..
4)
The
sum
of
Rupees_________________________________________(Initial
deposit
amount)standing at the credit of FD Account No(s) with your bank in the
name of Mr/Ms..
since deceased, without production of Letters of Administration or a Succession Certificate to his/her
estate or a Certificate from the Controller of Estate Duly to the effect that estate duly has been paid or
will be paid or none is due I/we do hereby for myself/ourselves and my/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 AND DELIVERED
By the above named on thisDay of two thousand
SIGNED AND DELIVERED by the above named

1. ____________________ 2. _____________________ 3._______________
2.
4._____________________ 5._____________________ 6._______________
(heirs /claimants of the deceased)
Exim Bank
Annexure - 3
RECEIPT
Received with thanks from Export-Import Bank of India, Mumbai , a sum of Rs. _______________
(Rupees _____________________________ only) by Bankers Cheque No.________________
dated ____________ in favour of ____________________________________________________ in
full and final settlement of my/our claim as successor on the balance in fixed Deposit Account(s)
No(s).. standing in the name of the deceased
Mr/Ms ________________________________. I/We do not have any other claim from the Bank
henceforth.
Place:
Date:
(Signature of all the legal heirs
Over a revenue stamp)
Exim Bank
Annexure - 4
DECLARATION in case funds are settled in favour of a Minor

I, father and natural guardian of
Master/Baby . hereby certify that
the proceeds of your Cheque No..dated..favoring
..issued by you in settlement of the balance in account
numberof Late.
will be utilized for the benefit of the minor only.
Signature of the guardian

Exim Bank Claim Form

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Exim Bank

the registered nominee in the above account(s).

VERIFICATION OF SIGNATURE AND PHOTOGRAPH OF THE ACCOUNT HOLDER

This is to certify that Mr /Ms..Son/Daughter of

Signature of above Account holder

Photograph of above Account holder

Signature of the Branch Manager:

Application for Deceased claim

The General Manager

Relationship with Deceased

(a) Whether Natural Guardian :.

I/We submit the following documents.

Please return the original death certificate to us after

1. Death Certificate (Original + 1 photocopy) issued by: ..

(To be duly stamped as per the Stamp Act applicable to the

LETTER OF INDEMNITY WITH RESPECT TO PAYMENT OF BALANCE IN THE DECEASED

IN CONSIDERATION of your paying or agreeing to pay me/us,

SIGNED AND DELIVERED by the above named

DECLARATION in case funds are settled in favour of a Minor

Signature of the guardian

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