Head Office: 66, Rajaji Salai,
Post Box No. 1384, Chennai – 600001.

CLAIM FORM CLAIM NUMBER:

BRANCH:
(Please see instructions in Page 6 for filling up the form)
1. DEPOSITOR
a. Name
b. Age
c. Address
d. Status (Married or Unmarried)
e. Religion ( If a Mohammedan, state whether Shia or Sunni)
2. Date of Death of Depositor (Authenticated death certificate to be enclosed)
3. Account(s) held by the Depositor
a. Nature of Account(s) such as
Current/SB/FD/RD/RIP/Agastiya / Jewel Loan etc., and Balance in the Account(s) to be furnished.
(In case of Time Deposits due dates to be furnished)
b. Documents in proof of amount(s)
claimed to be produced to the
Branch Office.
To be filled up by the Head Office
2
4. CLAIMANAT (S)
Name Age Relationship to the deceased
Occupation and address
5. If the deceased is a Hindu or Muslim male, whether he is survived by his
mother?

If so, her name and address to be furnished

If not alive, the date of her death to be given
6. Is the amount claimed
a. The coparcenary property or the separate property or interest in the property of a Tarwari, Tavazhi or IIiom or interest in the property of Kutumba of Kavaru or
Stridanam property.
b. If a Coparcenary property the names and addresses of the coparceners to be furnished.
3
7. If the deceased is a Hindu female, whether the amount claimed is from her
father or mother or from her husband or father-in-law.
8. If the deceased is a Mohammedan the names of he sharers, residuaries
and distant Kindred of the deceased with their respective shares to be furnished.
9. PROOF OF CLAIMANT’S TITLE
a. Whether by Inheritance or
b. Whether by bequest under a will
(authenticated copy to be furnished)
i. If so, the name(s) of the executor(s) if any appointed under the will to be given or
ii. Whether Succession certificate /Probate/
Letters of Administration obtained by the claimant or (the same to be produced)
Whether by Gift or Settlement (Document in proof thereof to be produced)
I/We hereby solemnly affirm that all the particulars furnished above are true, that
no part of it is false and that no information/particulars have been concealed and
4
that I am/we are the only heir(s) and/or Legal Representative(s) of the deceased
and there is no other claimant respect of the amount(s) claimed herein.
Place:
Date: Signature of claimant(s)
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Witnesses:
1. Signature………………………………………..
Name: --------------------------------------------------
Occupation:--------------------------------------------
Address:…………………………………………
…………………………………………………….
…………………………………………………….
…………………………………………………….
2. Signature………………………………………..
Name: --------------------------------------------------
Occupation:--------------------------------------------
Address:…………………………………………
…………………………………………………….
…………………………………………………….
…………………………………………………….
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Manager’s Report:
Note: Before giving the report, the Manager should,
i. See that all the columns in the claim form are filled in with specific
answers.
ii. Check up and certify as to the correctness of the particulars
furnished in column 3 of the form and
iii. Check up, obtain and send all the documents required to be sent
along with the form.
Date: Manager
6
INSTRUCTIONS FOR FILLING UP THE CLAIM FORM
1. All the columns should be filled in with specific answers
2. The form should be signed by all the heirs/claimants of the deceased.
3. If there are minor heir/s claimant/s, they should be represented by their legal
guardian.
4. If any of the heir/s claimant/s sign in any language other than the
language(s) in which the claim form is printed or affix his/her thumb
impression, the same should be duly attested by a Magistrate/Notary Public
under his official seal.
5. Letter from two respectable persons certifying to the correctness of the
particulars furnished by the claimants in the claim form should be sent along
with the claim form.
7
VOUCHING LETTER
From Place:
Date:
To
The Manger,
Indian Bank,
………………………..Branch.
Dear Sir,
Re: Claim to the balance in the ……………………………………………….account(s)
standing in the name of late………………………………………………………….
I know late Shri/Smt……………………………………………………………………and
the members of his/her family very well for the past ………………………years.
He/She passed away on …………………………………He/She is survived by the
under mentioned persons as his/her heirs:
Name Age Relationship to the deceased
I have gone through the claim form to which this letter is appended and I hereby
certify that the particulars furnished by the claimant(s) in the claim form are true and
correct to the best of my knowledge and information.
Yours faithfully,
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VOUCHING LETTER
From Place:
Date:
To
The Manger,
Indian Bank,
………………………..Branch.
Dear Sir,
Re: Claim to the balance in the ……………………………………………….account(s)
standing in the name of late………………………………………………………….
I know late Shri/Smt……………………………………………………………………and
the members of his/her family very well for the past ………………………years.
He/She passed away on …………………………………He/She is survived by the
under mentioned persons as his/her heirs:
Name Age Relationship to the deceased
I have gone through the claim form to which this letter is appended and I hereby
certify that the particulars furnished by the claimant(s) in the claim form are true and
correct to the best of my knowledge and information.
Yours faithfully,
9
CONSENT LETTER
From Place:
Date:
To
The Manager,
Indian Bank,
………………………..Branch.
Dear Sir,
Re: Claim to the balance in the ………………………………………………account(s)
standing in the name of late….....................................................................................
I am writing this to inform you that my …………………………………………..Sri/Smt.
………………………………………………………passed away on …………………….
leaving behind him as his/her heirs, the under mentioned persons.
Name Age Relationship to the Deceased
1.
2.
3.
4.
5.
The amount(s) /Jewels claimed under the above deposit/s account forms part of the
assets of the deceased. I am entitled to a share in his/her assets.
I hereby declare that I have no objection to the entire balance in the accounts/
jewels (including my share) being paid/ delivered over to my…………………………
Sri /Smt.……………………………………….I therefore accord my consent to the
balance in the accounts/ jewels being paid over/ released to him/ her. I further state
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that the discharge given by the said Sri/ Smt………………………………………. in
respect of the said deposits/ accounts shall be as effective as if the same is given
by me and binding on me.
Yours faithfully,
N.B.: In the case of thumb impression/ signature in any language other than the
language(s) in which the claim form and other papers are printed, the same should
be duly attested by a Magistrate or Notary under his official seal. While doing so,
the attesting official should state that the contents have been explained to and
understood by the signatory.
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A
………………………….. Branch
Identity Card for claimant(s)
Name of the Deceased……………………………………………………………………
1 2 3 4
Passport size
photograph of the
claimant
Passport size
photograph of the
claimant
Passport size
photograph of the
claimant
Passport size
photograph of the
claimant
……………………
(Signature of
the claimant/s)
……………………
(Signature of
the claimant/s)
……………………
(Signature of
the claimant/s)
……………………
(Signature of
the claimant/s)
5 6 7 8
Passport size
photograph of the
claimant
Passport size
photograph of the
claimant
Passport size
photograph of the
claimant
Passport size
photograph of the
claimant
……………………
(Signature of
the claimant/s)
……………………
(Signature of
the claimant/s)
……………………
(Signature of
the claimant/s)
……………………
(Signature of
the claimant/s)
The claimants who are personally known to us and whose photos are affixed above have
signed the claim form in our presence and also signed in this card in ours presence on
DD/MM/YY at ……………………..
Witnesses:
1. 2.
Name & address: Name & address: